CALVILLO.PDF

MARICOPA COUNTY 
Department of Finance 
301 West Jefferson, Ste 960 
Phoenix, Arizona 85003 
2018  DEC 30 Ati 9:18 	• 
 
14attv 
INTEROFFICE MEMORANDUM 
Date: 	
December 2, 2019 
To: 	
Clerk of the Board 
From: 	
Kathy Baskom 
Department of Finance 
Subject: 	
Affidavit — Replacement of Lost Warrant 
Please find attached affidavit for lost warrant to be included on the next available Board 
Agenda. 
• Attached is the affidavit / claim form for requesting a duplicate warrant of 
lost / never received warrant number 3010045699 the form needs to be 
signed by the claimant and notarized by a notary public. 
Thank you. 
Maricopa County Department of Finance 
Accounts Payable 
Attn: Kathy Baskom 
301 W Jefferson Street 
Suite 960 
Phoenix, AZ 85003 
)(1 D 
Dtpf 1. CID 9-0 4‘- 0:11 
LoO

Signed: 
(4) 
00.11 
(seal) 
GIOVANNI ESCOBAR 
Notary Public - Arizona 
Maricopa County 
Commission # 564232 
My Comm. Expires Apr 17, 2023 
NOTARY 
My commission expires: 
4j.tL ri  
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 	
Note: Numbers on this form correspond to 
COUNTY OF MARICOPA 	
numbers on the Instruction sheet which is 
page 2 of this form. 
BELEN CALVILLO 
Name/Claimant 
On or about 21-Oct-2019 
	
(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 $100.00 	
-(3 ) 
(1), being first sworn, upon oath deposes and says: 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
(5) Subscribed and sworfi to bire me this  iS-c4t" 
 day of 	
TA-4 f!--e  20 Pl. 
Warrant/Check Number 
(if known) (6)  
3010045699 
Original Date of Issue 
	
 (if known) (7)  
21-Oct-2019 
Reason for original issue of Warrant/Check (8): 
Payroll 
LI For Services or Goods furnished 	
 
D Treasurer's refund/payment 	  
Other: MUTT REFUND CHECK