STAMPED & REDACTED - TERRY ANN NILES.PDF

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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: 2-24-2023

Subject: Affidavit — Replacement of Lost Warrant

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

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 * 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 766 — D180 - OBF / TERRYANN NILES

OF ARIZONA
COUNTY OF MARICOPA
TERRYANN NILES

fart

On or about 23-Se

O22 _ (date)(2) 8 warrant/check
above named person/entity in the amount as stated below,
aither néver received or was subsequently inadvertently lost
no reasonable. prababllity of its being found or presented for payment,
presented for payment within one year after the date of issuance.

Therefore, uncer penalty of perjury, claimant hereby affirrns that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement

issued,to him/her in the sum of $141.63 3)

\,

Note, Please attath a copy of the warrant/check if avaiable andor any other
. evidence that a warrant/check was originally issued,

oo (8) Subscribed and sworn to before me this Q day of Fe bate cf 20.2
NOTARY PUBLIC ‘
OTARY PU JORDAN SMITH
y commission expires: Sa |
eh: /4, Tere Expires Oeiotae 44,2025 | (seal)
Warrant/Check Number
. (if known} (6) 301 01 28874
Original Date. of Issue ¢ ;
if known) (7) 23-Sep-2022 2/24/2023

~:,Reason for original Issue of Warrant/Check (8):
EF Payroll”.

al 4 : . : ? PSPRS Tiers 1 & 2 Excess Cantribution Relund » interest Portion Sept 2922
f2. For-Services:or Goods furnished i

iE) ‘Treasurer's refund/payment.
©) Other. check presumed lost / fund : 766 / GAX 23°914