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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM AE: Date: . May 13, 2021 ~CEy, Ds To: Clerk of the Board Chey Me. lq. Ma, From: Beth Brown are, On S Uy Department of Finance Pep ‘k Op, Subject: Affidavit — Notice of Claim Please find attached Affidavit for stale dated warrant to be included on the next available Board Agenda. e The attached item has been researched to ensure that 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: RICARDO ESPINOZA DEPT 750 FUND 675 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: LJ Duplicate or Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to COUNTY OF MARICOPA eos ee metuction sheet which is RICARDO ESPINOZA (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 20-Jun-2019 (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 $ 1,817.24 .(3) Signed: BA Mies lo (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 \\xh day of _ MAY 20 U\ A NOTARY PUBLIC My commission expires: OZ[to [wt (seal) Warrant/Check Number 3010036668 (if known) (6) Original Date of Issue 20-Jun-2019 (if krown) (7 Reason for original issue of Warrant/Check (8): C] Payroll [] For Services or Goods furnished CL] Treasurer's refund/payment Risk Management Settlement WC276119002831 Other: