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MARICOPA COUNTY 
Department of Finance 
301 West Jefferson, Ste 960 
Phoenix, Arizona 85003 
INTEROFFICE MEMORANDUM 
Date: 	
April 23, 2020 
To: 	Clerk of the Board 
From: 	
Beth Brown 
Department of Finance 
Subject: 	
Affidavit — Replacement of Lost Warrant 
RECEIVED 
APR 2 3 2020 	
z 
maRicoRn. COUNTY 
CLERK BOARD 
OF SUPERVISORS 
Please find attached affidavit for lost warrant to be included on the next available Board 
Agenda. 
• 
The attached item has been researched to ensure the warrant in question 
has not been cashed or previously re-issued. 
• 
The original warrant has a void/stale date/stop payment done. 
Please call me at 506-1329 if you have any questions. Please return the approved 
Affidavit to my attention in the Department of Finance, Suite 960. 
Thank you. 
Re: Elizabeth D Tate 
Fund 675 
Dept. 750

Signed: 
(4) 
(.5eal) 
NOTARY PUBLIC 
My commission expires: 
Attk22 , Zie-G  
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MOM COUNTY 
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Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: 	
Duplicate or 0 Stale-Dated (definitions are on page 2) 
STATE OF ARIZONA 
COUNTY OF MARICOPA 
Elizabeth a Tate 
Name/Clamant 
On or about 09-Apr-2020 	 (date)(2) a warrant/check was issued to the 
above named person/entity in the amount as stated below. Such warrant/check was 
either never received or was subsequently inadvertently lost or destroyed and there is 
no reasonable probability of its being found or presented for payment, gr it was not 
presented for payment within one year after the claim of issuance. 
Therefore, under penalty of perjury, claimant hereby affirms that this daim is correct 
and the amount shown is due and owing, and the applicant requests that a replacement 
warrant/check be Issued to him/her in the sum of $ / 6, u c. o . 	
.(3) 
Note Numbers on this form correspond to 
numbers on the Instruction sheet which is 
oaoe 2 of this form. 
(1), being first sworn, upon oath deposes and wys: 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a *want/check was originally issued 
(5) Subscribed and swOrhAq before me this 	
day ni." 	
i ) pr ,'  
20z6
- 
Warrant/Check Number 
(II known) (6) 
Original Date of Issue 
If Mown) (7 
2 01 00 5 (ite -?) 
Reason for original issue of Warrant/Check (8): 
Payroll 
0 For Services or Goods furnished 	
 
E Treasurer's refund/payment 	
 
17 Other: 	
I A 	
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