STAMPED & REDACTED - VICTORIA THORN.PDF

MAR ‘| COPA
COUNTY

Office of Budget & Finance To: Clerk of the Board
301 W. Jefferson St., 9 Floor

From: — Office of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003

Date: 3-28-2023
Subject: Affidavit — Replacement of Lost Warrant

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

Please find attached one Affidavit for a lost warrant to be included on the next
Maricopa.gov 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, gt Floor.

Thank you.

Re: Fund 675 — D750 / Risk Mgmt / VICTORIA THORN

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

This application is for: a 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.
VICTORIA THORN (1), belng first sworn, upon oath deposes and says:
On or about 01-Mar-2023 (date)(2) a wartant/check was Issued to the

above’ named person/entity in the amount as stated below, Such warrant/check was
either never received ot 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/chgt issued-to-tim/her in the sum of $ 103.78 (3)

Siang: a (4)

ef 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 swom to before me this A‘) day of March 20.42.

Chey tA, Wa tloreQ_

NOTARY PUBLIC

“CHERYLA, WALLAC!
Notary Public - Ste otainne

yy, mission expires: MARICOPA COUNTY.
mission #
V/AORS Explrae Mara iad (seal)

W t/Check Numb
arrant/Check Number | 3049444371

Original Date of Issue
(lf known) (7) 01 -Mar-2023

Reason for original issue of Warrant/Check (8);
[1 Payroll
For Services or Goods furnished RMD workmans comp

O Treasurer’s refund/payment
Other: check presumed lost / fund : 675 GAX1D 23719112

3/28/2023