STAMPED & REDACTED - FOR AGENDA ATTACHMENT - VALLEY UTILITIES WATER COMPANY INC.PDF

v
MAR COPA
COUNTY

Office of Budget & Finance
301 W. Jefferson St., 9* Floor
Phoenix, Arizona 85003

P: 602-506-3561
F: 602-506-4451

Maricopa.gov

To: Clerk of the Board
From: Office of Budget & Finance, Accounts Payable
Date: 5.5.23

Subject: Affidavit — Replacement of Lost Warrant

Please find attached one Affidavit for a lost warrant to be included on the next
available Board Agenda.

e The attached item has been researched to ensure the warrant in question has not
been cashed or previously re-issued.

e The original warrant is presumed fost.

Please call Joyce Maurmann at 506-1343 if you have any questions. Please return the
approved Affidavit to my attention in the Office of Budget and Finance, 9 Floor.

Thank you.

Re: Fund 232 — D640 / Valley Utilities Water Co., Inc.

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Duplicate or (1 State-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

paqe 2 of this form.

Valley Utilities Water Co., Inc. (1), being first sworn, upon oath deposes and says:
On or about 15-Dec-2022 (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 tha amount shown is due and owing, and the applicant requests that a replacement

watrant/check be4ssued to him/her in the sum of $226.42 (3)
Signed: LE (4)

Note; Please attach a copy of the wartant/check if available and/or any other
evidence that a warrant/check was originally issued.

(5) Spbscribed and ie me this__ 87° day of Cebrunny 2023,
~

A ANG eit. «
NOTARY PUBLIC

VERONICA G GONZALEZ
Notery Publo, State of Arizane
Maricopa County = *
Commission # 589848
My Commission Expires
August 16, 2023 (seal)

—_

My commission expires;
Paras I Bee

Maren ome 3010137096
Original Date of Issue 15-Dec-2022

5
Reason for original issue of Warrant/Check (8): = izaiopS

O Payroll
For Services or Goods furnished_/ utility bill

0 Treasurer's refund/payment _-
Other: / check presumed lost / fund : 232 / D640

Valley
Utilities
Water Co. Inc.

May 3, 2023

|, Bryan Thomas, authorize Veronica Gonzalez, Customer Service Representative,
to execute an affidavit on behalf of of Valley Utilities Water Co.

Yours truly,

Lo-

Bryan Thomas, President