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~ 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: Subject: Affidavit — Replacement of Lost Warrant Please find attached one Affidavit for a lost warrant to be included on the next available Board Agenda. « 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 cail 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 675 — D750 / Victoria Thorn Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or L] Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this ferm correspond to COUNTY OF MARICOPA numbers on the Instruction sheet which is pade 2 of this form. VICTORIA THORN (1), being first sworn, upon oath deposes and says: Name/Clalmant On or about 30-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/ch@ck be issued to him/her in the sum of $ 103.78 (3) Signe’ (4) 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 sworn to before me this 7 day of Apri | 20823. OTARY PUBLIC My commission expires: z Y P Gili, CHERYLA. WALLACE Notary Public - State of Anzona (seal) MARICOPA COUNTY. Commigaton # A00778 TAPE March 14, 2028 | Warrant/Check Nurnber 304 Gaperay _ (if known) (6) Original Date of Issue (if known) (7) 30-Mar-2023 . 4/28/2023 Reason for original issue of Warrant/Check (8): = ( Payroll For Services or Goods furnished / Workman comp C1 Treasurer’s refund/payment Other: / check presumed lost / fund ; 675 / GAX1D : 23°19112