STAMPED & REDCATED - FOR AGENDA ATTACHMENT - CITY OF TEMPE WATER DEPT_REDACTED.PDF

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.gov

To: Clerk of the Board

From: — Office of Budget & Finance, Accounts Payable
Date: = 4/17/2023

Subject: Affidavit — Replacement of Lost Warrant

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

« 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 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 572 — D700 / CITY OF TEMPE WATER DEPT

Application 1 fora Duplicate or Stale-Dated Warrant/C Check a
Affi davit/ Claim Form _

This application is for: Duplicate or (] Stale-Dated (definitions are on page 2)

STATE OF ARIZONA _ | Note: Numbers on this form correspond to”

COUNTY OF MARIGOPA numbers on the Instruction sheet which is
page 2 of this form.

CITY OF TEMPE WATER DEPARTMENT (1), being first sworn, upon oath deposes and says:
“Name/Claimant

On or about 24-Feb-2023 (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
eithier 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 Pe, issued to him/her in the sup of $1, 275.21 -(3)

Signed: th Ly he Le TA (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 iS day of ow 20a3 .

A rae ee
OTARY PUBLIC

My commission expires:

GRISTIMA CORONEL
Notary Public - AMzona
Maricopa County
Commission # 582775

ow los! aaa dy Comm, Expires Jun 3, 2024 (seal)
Warrant/Check Number
(if known) (6) 3010143907
Original Date of Issue
(it known) (7) 24-Feb-2023

ar 4/18/2023
Reason for original issue of Warrant/Check (8): -

O Payroll
O For Services or Goods furnished

(J Treasurer's refund/payment
Other: LOST WARRANT -FUND 572 - D790 -UTILITY INVOICE- GAX1D 23°18800

rr
i

City of Tempe

April 6, 2023

|, Lisette Camacho, authorize Tarja Nummela, Customer Services Manager, to execute an affidavit on behalf of
City of Tempe.

Yours truly,

» wo
Lisette Camacho

Financial Services Director

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY
PHOENIX,ARIZONA WARRANT NUMBER

DATE

One Thousand Two Hundred Seventy Five And 21/100 Dollars
PAY TO THE ORDER OF
CITY OF TEMPE WATER DEPT avout —
Void After
po “eee

For Questions - 602-506-1379 or email AP@MAIL. MARICOPA,GOV
MARICOPA COUNTY DEPARTMENT OF FINANCE

NOT NEGOT.
RETAIN THIS FOR | PAYEE WARRANTNO. | WARRANT TABLE
YOUR RECORDS ip
CITY OF TEMPE WATER DEPT 301.0143907 O22420% WARRANT AMOUNT
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | vouces=
CER NO
7198000000223  |ACCT# 7198000000 GAX1D D700 23000@5
230000018800 Oiea00
719go000000223 © |ACCT# 7198000000 GAX1D D700 23000,
230000018800
6190000000223 © |ACCT# 6198000000 GAX1D D700 23000, 97.16
230000018813 ©15843
6198000000223 | ACC T# etg8ono000 GAX4D D700 23000 856.63
230000048813 S18813 198.14