STAMPED & REDACTED FLOR LIZETTE LUNA.PDF

301 West Jefferson 999] HAY -3 PH 3:09
Phoenix, Arizona 85003
Head
INTEROFFICE MEMORANDUM |
Date: May 3, 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: 200 / Dept: Human Services : / Company: FLOR LIZETTE LUNA

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
pade 2 of this form.
FLOR LIZETTE LUNA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-Mar-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 | is due and owing, and the applicant requests that a replacement
shown
warrant/chec’be to him/her in the sum of ¢ 7,500.00 (3)
issued
Signed: ! (4)
SS
Note: Pléase ttacf a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
16 Reri | 2021
(5) and sworn to before me this _ 4% _ dayof .
Subscribed
NOTARY PUBLIC RICHARD L, BAUER
set SK NOTARY PUBLIC » ARIZONA
\
expires: ooitisslon 4 597268
My comm Ission ey):
pec I$ WH 27 My Contin, Exp, Dec. 28, 2024 (seal)
Warrant/Check Number | 3940083896
(if known) (6)
Original Date of Issue 05/04/2021 /04,
05-Mar-2021
(it known) (7) ;
Reason for original issue of Warrant/Check (8):
[J Payroll
/ COVID rental payments
a For Services or Goods furnished
1 Treasurer's refund/payment
/ original check presumed lost in the mail
Other:

Letter of Authorization
af2772i
i, Flor Luna, iam the sole and only owner / proprietor of my company. | authorize myself to execute the affidavit/ claim
form.
Thank you,
Flor Lizette Luna
Owner