STAMPED & REDACTED REGINA JUAREZ.1.PDF

MARICOPA COUNTY BOARD OF SUPERVISOR'S AT
Office of Budget and Finance - oe
(Del he
301 West Jefferson 202i HAY 17 ANTI: &S
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 17, 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:675 /Dept: Risk Mgmt / Company : REGINA JUAREZ

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: Duplicate or LJ 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.
REGINA JUAREZ (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 19-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 $ 1,306.62 .(3)
ose SN
Signed (4)
Not’ nase aac? a copy of the warrant/check if available and/or any other
evide, a warrant/check was originally issued.
(5) Subscribed and-sworroe before me this 7 _ day of Mire 20_.)) .
NOTARY PUBLIC~ rete pron k Dita Los tes ea SG
i)" JOSEPH CONNELLY 3
Notary Public - Arizona a)
My commission expires: Maricopa County
Commission # 558198
DAi¢- 20753 = Feb 18 (g@al})
Warrant/Check Number
3010086950
(if known) (6)
Original Date of Issue
et 19-Apr-2021 05/18/2021
Reason for original issue of Warrant/Check (8):
C1 Payroll
For Services or Goods furnished_/ Workman comp. checks
O1 Treasurer's refund/payment
/ Original check presumed lost in the mail
Other:

Walter Chang (FIN)
From: FIN AccountsPayable
Sent: Monday, May 10, 2021 1:15 PM
To: Regina Juarez
Ce: Walter Chang (FIN); Beth Brown (FIN); Joyce Maurmann (FIN); FIN AccountsPayable
Subject: RE : Checks not received
Hello Regina. Please mail the two original affidavits to :
Maricopa County
Office of Budget and Finance
Accounts Payable
W. Jefferson St.
Phoenix, AZ 85003
If you use FEDEX we are temporarily located on the 4th floor.
,
Thank you.
Walter Chang
Maricopa County Office of Budget and Finance
From: Joyce Maurmann (FIN) <
Sent: Monday, May 10, 2021 12:29 PM
To: Walter Chang (FIN)
Cc: Beth Brown (FIN) <
Subject: RE: Checks not received
Hi Walter,
| reviewed the documents, please have payee mail them.
Thanks,
Joyce Maurmann
Accounts Payable Supervisor
Maricopa County Department of Finance