SIGNED & REDACTED PALM MOBILE HOME PARK RV LLC.PDF

Office of Budget and Finance, »- me ay
301 West Jefferson Street , Ste ‘960. —
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: February 22, 2021 5
To: Clerk of the Board 3
From: Walter Chang ra
Office of Budget and Finance a
Subject: Affidavits — Replacement of Lost Warrants
ee
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 Suite 960.
,
Thank you.
Re: Fund: 200 /Dept: Human Services / Company: Palm Mobile Home Park RV LLC

Application for a Duplicate or Stale-Dated Warrant/Check F Ge
Affidavit/Claim Form
This application is for: [4] Duplicate or C1 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
Palm Mobile Home Park RV LLC (1), being first sworn, upon oath deposes and says:
‘Name/Claimant °
On or about 25-Nov-2020 (date)(2) a watrant/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 reasoriable 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 ¢ 7,900,00 (3)
INN TF.
Signed: (4)
7
Note. Please atiach 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 day of 20
My commission expires: \. ac Af. co
x < a
(seal).
Cali Poe Na erat tor oy
arrant/Check Number 3040075063
|
Original Date of Issue ng Ni qy_91)4
Reason for original issue: of Warrant/Check (8):
1 Payroll
(1 Treasurer's refund/payment
2 Other: _/ Original check presumed lost
02/23/2021

( Mfeclavi i | Claivn em and dated_ Z | 5 | 202 (
This certificate is attached to a page document dealing with/entitled
California 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 San ego
Subscribed and sworn to (or affirmed) before me on this S th day of
Bill G. Zheovo
,202(_, by
Felorvacy
proved to me on the basis of satisfactory evidence to be the person(é) who appeared
before me.
ASS. COMM.#2271444 Sf
Pert NOTARY PUBLIC - CALIFORNIA
sY «6=©6s SAN: DIEGO COUNTY
My Comm. Expires Dec. 16,2022
===
signature
Printed 01-18
Produced by MarkMaster, Inc. | 1.800.441.MARK | www.markmasterinc.com

Palm Mobile Home Park RV LLC
Gila Bend, AZ 85337
1/21/2021
|, Carol S. Lam, authorize Bill G. Zhou, Administrator, to execute an affidavit on behalf of Palm
Mobile Home Park RV LLC.
Yours truly,
GA OMe dle
Carol S. Lam
LLC manager

ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individuai
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 _Gaw (dF )
=QO
om 221 Rermurcs| B. Ceacdac, k Macy Behd
On Pelpeuatty before me,
(insert name and title of the officer)
personally appeared Cac o| Loy
namels}
who proved to me on the basis of satisfactory evidence to be the person(s} whose is/are
subscribed to the within instrument and acknowledged to me that Aé/she théy executed the same in
al authorized capacity(je$), and that by his/her/theif signature(g) on the instrument the
a
person(g), or the entity upon behalf of which the person(g) acted, executed the instrument.
| certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
emi ROMMEL B. CACDAC
WITNESS my hand and official seal. - COMN.# 2271444
5 =:
Wes a n} NOTARY PUBLIC - CALIFORNIA
S 3 SANDIEGO COUNTY ;
Late My Comm. Expires Dec. 16, 2022
&
Signature ae a eee (Seal)

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