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v MARICOPA COUNTY Office of Budget & Finance 301 W. Jefferson St., 9% Floor Phoenix, Arizona 85003 P: 602-506-3561 F: 602-506-4451 Maricopa.gev To: Clerk of the Board From: Office of Budget & Finance, Accounts Payable Date: 5/24/2023 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 lost. Please call Walter Chang at 506-8747 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 219 — D190 / Luis Montalvo Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or [7] 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 . pade 2 of this form, Luis Montalvo (1), being first sworn, upon oath deposes and says: ame/Claiman On or about 23-Mar-2023 (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 $4,501 29 (3) Signed: Lollber (4) Note. Please attach a copy of the watrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this j/% day of Ma VA 20 33. NOTARY PUBLIC My commission expires: LEALIt( BD € eS eal) Warrant/Check Numbe rrantCheck Number 13010146062 Original Date of Issue gna einen) 23-Mar-2023 5/24/2023 Reason for original issue of Warrant/Check (8): O Payroll Ci For Services or Goods furnished Treasurer’s refund/payment Other: Victim Compensation Check: 1862103-1-Rast4