REDACTED FOR AGENDA ATTACHMENT -PINE VALLEY ONE REAL ESTATE LLC .PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: January 17, 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 cail 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:100 /Dept:430 -
Treasurer / Company: Pine
Valley One Real Estate LLC
affidavit

Pine Valley One Real Estate, LLC

January 17, 2023

I, Todd Eichmann, authorize Evan J. Hareras, Administrator, to execute an affidavil on behalf of Pine ‘Valley One Real
Estate, LLC.

Your truly,
fe
Todd Eichmann

Operations. Manager

Chicago, It 60602

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

This application is for: oO 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

. paae 2 of this form.
Pine Valley One Real Estate LLC (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 02-Feb-2021 (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 $4,900.38 (3)

Signed: - per Sf (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 Zt th day of Jany ary 202 3.
WeusuthuX
PUBLIC i =

AJEENAH MURARSHEED
OFFICIAL SEAL
Notary Public, State of Illinois
3 4) My Commission Expires

S February 22, 2025 (seal)

SIBLE,
Paps

My Pep expires:

Warrant/Check Number 920748 .

(if known) (6)
Original Date of Issue
(if. known) (7) 02-Feb-2021

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

O Payroll
For Services or Goods furnished_/ Parcel # 102-73-267 and 102-86-337

O Treasurer’s refund/payment
Other: / check presumed lost / fund : 100