STAMPED & REDACTED-LAUNA CAMPOS.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM
Date: January 27, 2023
To: Clerk of the Board

From: Walter Chang
Office of Budget and Finance

Subject: Affidavits - Replacement of Lost Warrants

Please find attached 1 Affidavits for lost warrants to be included on the next available

Board Agenda.
e The attached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.

e The original warrants have a void/stale date/stop payment done.

Please call me at if you have any questions. Please return the approved
affidavits to my attention in the Office of Budget and Finance.

Thank you.

Re: Fund: 766 /Dept: OBF /
Company : LAUNA CAMPOS

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

This application is for: Duplicate or 1] state-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
oaae 2 of this form.

LAUNA CAMPOS (4), being first sworn, upon oath deposes and says:
ame, jaiman :
On or about 23-Sep-2022 (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/check be issued to him/her in the sum of $ 128.73 .B)
So gee
Signed: j (A (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 2S day of Nun Maly 2023.

NOTARY PUBLIC [te | ERIC DIAZ

Notary Pubic - State of Arizona
MARIGOPA COUNTY
Commission # 648584

Expires December 14,2025 { (seal)

My commission expires:
i2:1y 202s

W. t/Check Numb
arrant/Check Number 13010128409

Original Date of Issue
(if known) (7) 23-Sep-2022 1/31/2023

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

1 Payroll

# PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022

For Services or Goods furnished

C1 Treasurer’s refund/payment
Other: / check presumed lost / fund : 766 / D180

WARRANT NUMBER

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY
PHOENIX, ARIZONA 3010128409
DATE
69-23-2022 94:2/1224
One Hundred Twenty Eight And 73/100 Dollars
$128.73
PAY TO THE ORDER OF
AMOUNT
LAUNA CAMPOS
Void After
365 Days
Vor Questions + oremali.. NOT NEGOTIABLE
MARICOPA-COUNTY DEPARTMENT OF FINANCE
RETAIN THIS POR.) PAVEE WARRANT NQ. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
PSPRS INT PAYMENT 3010128409 09/23/2022 $128.73
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO, | VOUCHER NO. AMOUNT
PSPRS Tiers 1.& 2 Excess Contribution Refund - |; GAX D480 230000000198 | 230000000198 428.73

PSPRS172

Portiory Sept 2022

RECEIVEDBY ti‘

MARICOPA COUNTY
D.OF.

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RECEIVED BY —

JAN 27 2023
MARICOPA COUNTY
DOF.

mA PMaANCE