STAMPED & REDACTED AZ STATE LIBRARY.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: June 29, 2021
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached affidavit for 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 has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: AZ STATE LIBRARY
DEPT
RECEIVED
FUND 205
A
JUN 29 2023
hard Dolor el
MAHICOPA COUNTY
CLERK BOARD OF
SUPERVISORS

St
7972 Oo
KATIE HOBBS
SECRETARY OF STATE
State of Arizona
June 23, 2021
|, Sarah Brown, authorize Victoria Tafoya, Director of Finance, to execute an affidavit on behalf of the
Secretary of State’s office.
Yours truly,
Sarod Brown
Sarah Brown
Chief Financial Officer
Arizona Secretary of State Katie Hobbs
Phoenix, AZ 85007-2808

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.
AZ ATE Ee rey (1), being first sworn, upon oath deposes and says:
a
On or about 91-Apr-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 ¢ 75,000.00 (3)
Yield Sof Or
Signed: \ (4)
Note, Please attach a Spy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscfibed and sworrte before m this ath day of VGUNE 20 )
AN
NOTARY PUBLIC ()
: DIANA OGAZ
My commission expires: MARICOPA COUNTY
“aes cameeeieer | xan
—
W Check Numb
arrantCheck mumper 13010085682
Original Date of Issue
01-Apr-2021
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
For Services Goods fu rnished Annual funding for electronic records repository program, 3/1/2021-02/28/2022
or
—_
1 Treasurer's refund/payment
~~
O Other:
06/30/2021