STAMPED - OPID CHANDLER LLC DBA MIRA SANTI.PDF

MARICOPA |
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: = 2-8-2023 be
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, 9* Floor.

Thank you.

Re: Fund 222 — D220 - Human Services / OPID CHANDLER LLC , DBA MIRA SANTI

\ hou

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/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 MARICOPA numbers on the Instruction sheet which is
page 2 of this form.

OPID CHANDLER LLG , DBAMIRA SANTI (1), being first sworn, upon cath deposes and says:
Nameé/Claimant

On or about 03-Nov-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, gr 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 $ 5,965.17 (3)

Signed: LL. MCL EOE. Po (4)

Note: Please attach a copy of, warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this tnd day of Eobeuary 20 23 .

maa

NOTARY PUBLIC a OFFICIAL SEAL
JOVANI GOMEZ

. NOTARY PUBLIC - ARIZONA
My commission expires: NC eee
Dec.21% Lob a

Warrant/Check Number
(if known) (6) 301 01 33074

Original Date of Issue ;
(if known) (7) 03-Nov-2022 2/9/2023

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

Cl Payroll-
For Services or Goods furnished / Santoya, Sienna - Rental Assistance

C Treasurer's refund/payment
Other: / check presumed lost / fund : 222 / GAX1D 23*9990

Mira:Santi

NTS

LUXURY APART

1/31/2023

|, Adam Mallett, authorize Madison Armstrong, Assistant Manager, to execute an affidavit on behalf of
Mira Santi Apartments.

Regards,

Adam Mallett

Manager of Community Operations oO

Hoje

Mark dN Taylor