REDACTED - FOR AGENDA ATTACHMENT- JOES BACKHOE SERVICE.PDF

MARICOPA
COUNTY

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

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

Maricapa.gov

To: Clerk of the Board
From: Office of Budget & Finance, Accounts Payable
Date: 5.17.23

Subject: Affidavit — Joes Backhoe Service C/O Joseph S Gibson

Please find attached one Affidavit for a stale dated 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.

@ The original warrant is presumed lost.

Please call Marcia Bulanda at 506-7291 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: STALE DATED - FUND 226 ~ D440 -REFUND #B202105102 CREDIT RECEIPT
#R202210778R — GAX1D 22422437

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: im Duplicate or 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.

JOES BACKHOE SERVICE C/O JOSEPHS SIBSON (4) heing first sworn, upon oath deposes and says:
~Wame/Chaimant

On or about 02-May-2022 (date)(2) a warrant/check was isstied 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 replacernent

raat fons ope sum of ¢ 1,148.00 .(3)
C

Signed: ‘ 4

iS iF (4)

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

_ Subscribed and sworn to before me this [ELK day of 4 os 2073.

Zl
GRRE PUBLIC a

glENNICA LOYD
My commission expires: believed Sue thine
Q¢/ 22/2024 bp Sembee a ae (seal)
Warrant/Check Number
{if known) (6) 301 01 16172
Original Date of Issue
(if known) (7) 02-May-2022

Reason for original issue of Warrant/Check (8):
C1 Payroll
For Services or Goods furnished / MREFUND

CD Treasurer’s refund/payment
Other. {check presumed lost / fund : 226