TAYLOR MONTGOMERY.PDF

MARICOPA COUNTY 
Department of Finance 
301 West Jefferson, Ste 960 
Phoenix, Arizona 85003 
INTEROFFICE MEMORANDUM 
Date: 	January 28, 2020 
To: 	
Clerk of the Board 
From: 	
Marcia J. Bulanda 
Department of Finance 
Subject: 	
Affidavit — TAYLOR MARIE MONTGOMERY 
Please find attached 1 Affidavit for stale dated warrant to be included on the next available 
Board Agenda. 
O The attached items have been researched to ensure the warrant in question 
have not been cashed or previously re-issued. 
• 
The original warrant is lost. 
Please call me at 506-7291 if you have any questions. Please return the approved 
Affidavits to my attention in the Department of Finance, Suite 960. 
Thank you. 
Re: 
TAYLOR MARIE MONTGOMERY STAMPED AND SIGNED BY B.O.S. (SEE ATTACHED AFFIDAVIT)

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 	
2020 JAN 23 AM O'c' 
OFFICIAL SEAL 
Jolene E Aylward 
NOTARY PUBLIC - ARIZONA 
Maricopa County 
COMM # 560297 
My Comm, Expires March 3, 2023 
r 
(seal) 
This application is for: 0 Duplicate or 0 Stale-Dated (definitions are on page 2) 
STATE OF ARIZONA 
COUNTY OF MAR ICOPA 
TAYLOR MARIE MONTGOMERY  (1), being first sworn, upon oath deposes and says: 
NanneiClarmant 
On or about 23-A11-21319 
	
(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, or it was not 
presented for payment within one year after the date of issuance. 
Therefore, under penalty of perjury, claimant hereby affirms that this claim 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 $ 179 -25 
/7 
 
Signed: 	
( 
(,),A) 
 
Note: Please Oltach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
(5) Subscribed and sworn to before me this (D° 
	day of 
arc, 20.aD 
Note: Numbers on this form correspond to 
numbers on the Instruction sheet which is 
ramie 2 of this form. 
.(3) 
(4) 
1:7) 
 
NOT-A
• i
RY PUBLIC 
My commission expires: 
Warrant/Check Number 
(If known) (6)  
3010039348 
Original Date of Issue 
(If known) (7)  
23-Jul-2019 
Reason for original Issue of Warrant/Check (8): 
O Payroll 
D For Services or Goods furnished 	
 
D Treasurer's refund/payment 	
 
oiher: MREFUND (FUND 100-D240-JUSTICE COURTS-GAX1D 	
fJ * map