REDACTED UMEH VICTOR 899198 WARRANT.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 21, 2021
To: Clerk of the Board
From: Beth Brown
Department of Finance
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: UMEH VICTOR

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/ Claim Form
This application is for: LI Duplicate or Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA eae ihr tales instruction sheet which is
UMEH VICTOR (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 15-Nov-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 pepalty of perjury, claimant hereby affirms that this claim is correct
and the amountshown is due and owing, and the applicant requests that a replacement
Kosa
warrant/: hn in the sum of $94.70 (3)
pa
|
Signed: << / (4)
Please
Note. attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
ERT
(5) Subscribed and sworn to before 20
pen
NOTARY PUBLIC CE RTIFICATE
NOTARIAL
nee ATTACHED
SEE
mission expires:
(seal)
TWarrant/CheckNumber leaa1oo. © ~*W
899198
(if known) (6)
Original Date of Issue
Reason for original issue of Warrant/Check (8):
OO Payroll
C1 For Services or Goods furnished
Never received
Treasurer's refund/payment
O Other:

JURAT
A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of Sacramento
,
Sf
|e IY
Subscribed and sworn to (or affirmed) before me on this _! “day of ale sae
Vi ttoR_ U met
2021 by
proved to me on the basis of satisfactory evidence to be the person(s) who appeared
before me.
eee eee eee OT
KHALIUN GANSUKHg
ge COMM. # 2320435
NOTARY PUBLIC - CALIFORNIA)
DM, L Le BSy=W
Ae eS) SACRAMENTO COUNTY ()
ak COMM. EXPIRES FEB 28, 202424
Signature
(Seal)
OPTIONAL INFORMATION INSTRUCTIONS
The wording of all Jurats completed in California after January 1, 2015 must be in the
form as set forth within this Jurat. There are no exceptions. If a Jurat to be completed
does not follow this form, the notary must correct the verbiage by using a jurat stamp
containing the correct wording or attaching a separate jurat form such as this one with
does contain the proper wording. In addition, the notary must require an oath or
DESCRIPTION OF THE ATTACHED DOCU affirmation from the document signer regarding the truthfulness of the contents of the
document. The document must be signed AFTER the oath or affirmation. If the document
was previously signed, it must be re-signed in front of the notary public during the jurat
(Title or description of attached document) process.
e State and county information must be the state and county where the
document signer(s) personally appeared before the notary public.
(Title or description of attached doetiment continued)
Date of notarization must be the date the signer(s) personally
appeared which must also be the same date the jurat process is
,
completed.
_____ Document Date____ Print the name(s) of the document signer(s) who personally appear at
the time of notarization.
Signature of the notary public must match the signature on file with the
Adgitfonal information office of the county clerk.
The notary seal impression must be clear and photographically
reproducible. Impression must not cover text or lines. If seal impression
smudges, re-seal if a sufficient area permits, otherwise complete a
different jurat form.
“* Additional information Is not required but could help
to ensure this jurat is not misused or attached to a
different document.
Indicate title or type of attached document, number of
pages and date.
2015 Version www.NotaryClasses.com 800-873-9865 Securely attach this document to the signed document with a staple.