STAMPED AND REDACTED - 3010226375 - POINT AND PAY LLC.PDF

Office of Budget & Finance To: Clerk of the Board
301 W. Jefferson St., 9th Floor From: Office of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003
Date: 9-3-2026
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.
• The attached item has been researched to ensure the warrant in question has not
been cashed or previously re-issued.
• 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, 9th Floor.
Thank you.
Re: Fund : 100 / Dept : 290 – Medical Examiner / vendor name : Point and
Pay, LLC

Application for a Duplicate or Stale Dated
Warrant/Check Affidavit/Claim Form
This application is for I II I Duplicate or D Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form
_P_O_I _N _T _ A_N_D_P_A _Y..,., _L L_C _________ (1 ), being first sworn, upon oath deposes and says:
Name/Claimant
on or about 13-N OV-2025 (date) (2) a warrant/check was issued to the above named
person/entity in the amount 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
um of$ 322.22 . (3)
.,.-;
Signed:_:J ______________________ (4)
Print Name: (required) _M_a_r_c_M_ o_s_k_ow_itz_,_c_o_o ___________ _
Note: Please attach a copy of the warrant/check if available and/or any other evidence that a
warrant/check was originally issued.
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NOTARY PUBLIC
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1 Not,ry Public Sl1te of Florid• 1
1 .._ • Ch1rl1n1 Nicole Lopez •
My commission expires: 1 1111 My Commlulon HH 357722 1
1 Expires 21212021 ( seal)
Z/Z/7orz 7 --- - ----
Warrant/Check Number
(if known) (6) 3010226375
Original Date of Issue
13-NOV-2025
(if known) (7)
Reason for original issue of Warrant/Check (8):
□ Payroll ____________________________
□ For Services or Goods furnished ___________________ _
□ Treasurer's refund/payment ____________________ _
EJ Other: D290-Medical Examiner - Fund 100-1.N. 26*27903 & 26*27080 - Credit Card Processing, As Needed
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\ 100518 Warrants Checks notice of claim.doc Revised
100518
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