STAMPED WEST VALLEY MC LLC DBA KELLER WILLIAMS ELITE.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
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INTEROFFICE MEMORANDUM Oo 3e
Date: March 9, 2021 2 be i
To: Clerk of the Board . eG
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From: Beth Brown ee
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached affidavit for lost warrant to be included on the next available Board
Agenda.
e The attached item has been researched to ensure the 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: WEST VALLEY MC LLC, DBA KELLER WILLIAMS ELITE
DEPT 220
FUND 200

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or ["] 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.
WEST VALLEY MC LLC, DBA KELLER WILLIAMS ELITE (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 13-Jan-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
be issued to him/her in the sum of $ 1,500.00 (3)
7)
Signed: _( — O3/s G [ 22s) (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 S day of Marth 202\.
LUIS C. FLORES JR.
NOTARY PUBLIC lz Notary Public - Maricopa County
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Commission No. 596213
My commission expires: Sco? E «MY Sommmnisalon Expires
January 13, 2025
\-1%- 202¢7— (seal)
Warrant/Check Number 100791
30 61
(if known) (6)
Original Date of Issue
13-Jan-2021
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
COVID RENTAL ASSISTANCE
For Services or Goods furnished
C1 Treasurer's refund/payment
{] Other:
03/09/2021

KELLERWILLIAMS.
REALTY ELITE
Jerry Kyle Christian, the Designated Broker for Keller Williams Realty Elite, is an authorized
signer for Keller Williams Realty Elite.
Signed Gwendolen Gott
Operating Principal
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