STAMPED & REDACTED SUMER HOWARD.PDF

MARICOPA COUNTY
Office of Budget and Finance
301 West Jefferson
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 24, 2021
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 506-8747 if you have any questions. Please return the approved
affidavits to my attention in the Office of Budget and Finance.
Thank you.
Re: Fund: 241 /Dept: 300 - Parks and Rec/ Company: Sumer Howard

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form |
This application is for: Duplicate or [J 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.
.
sumer Howard (1), being first sworn, upon oath deposes and says:
e. 1
On or about 96-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 ued to him/her in the sum of $ 214.00 (3)
Signed: ; (4)
C/
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
5) Subscried and sworn to before me this [
Vs aby
NOTARY PUBLIC/”
WENDY FARIVAR
<2) Notary Public - State of Arizona
YAVAPAI COUNTY
My commission expires: ( kJ Commission # 595806
LY (— A & a of 6 a a Expires January 06, 2025 (seal)
Warrant/Check Number
3010085961
(if known) (6)
Original 3 Date of Issue 05/24/2021
06-Apr-2021
(if known) (7) ry
Reason for original issue of Warrant/Check (8):
C1 Payroll
#38791
Fl For Services or Goods furnished_/ Refund Sale
1 Treasurer’s refund/payment
/ Original check presumed lost in the mail
Other:

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