STAMPED & REDACTED - MALAIKA JOHNSON.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: 3-28-2023

Subject: Affidavit — Replacement of Lost Warrant

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

s 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 222 — D220 / Human Services / JOHNSON , MALAIKA

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: Duplicate or C1] 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.
JOHNSON, MALAIKA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 08-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
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

Signed: (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 tobefore me this day of 20

NOTARY PUBLIC ‘
\s alttoadnment=

%
\ (seal)

My commission expires:

Warrant/Check Number | 3949142551 :

(if known) (6)

Original Date of Issue
(if known) (7) 08-Feb-2023

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

O Payroll

For Services or Goods furnished JOHNSON, MALAIKA - RENTAL ASSISTANCE / direct pay

C1 Treasurer's refund/payment
Other: {check presumed lost / fund : 222

3/28/2023

CALIFORNIA JURAT GOVERNMENT CODE § 8202

A notary public or other officer completing this certificate verifies only the identity of the Individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

i
i
i
|

State of California

County of _ Fresno

Subscribed and sworn to (or affirmed} before me on

this _28th_ day of __March 20.23 by
Date Month Year
(1) Malaika T. Johnson
eevee
{and (2) ),
ro
CHOU YUE Name(s) of Signer(s)
Notary Public - California. = &
Fresno County = proved to me_on the basis of satisfactory evidence to

{ = ay een ons ; be the person(s) who appeared before me,
Signature La

Place Notary Seal and/ar Stamp Above Signatire of Notary Public

OPTIONAL ~--—--——- a

Completing this inforraation can deter alteration of the document or
fraudulent reattachment of this form to an unintended documeni.

Description of Attached Document

Title or Type of Document: _ Application for Duplicate/Stale-Dated Check - Affidavit/Claim Form

Document Date: Number of Pages:

Signer{s) Other Than Named Above:

12019 National Notary Association