SIGNED & REDACTEDERNIE SCHROER DBA PEORIA POLYNESIAN VILLAGE.PDF

MARICOPA COUNTY
Office of Budget and Finance
301 West Jefferson Street Ste 960
,
Phoenix, Arizona 85003
1202
INTEROFFICE MEMORANDUM
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Date: February 4, 2021
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To: Clerk of the Board
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From: Walter Chang | we
Office of Budget and Finance
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Subject: Affidavits — Replacement of Lost Warrants oy o
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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: 220-Human Services / Company : ERNIE SCHROER

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
pade 2 of this form.
ERNIE SCHROER DBA:PEORIA POLYNESIAN VILLAGE é ) being first sworn, upon oath deposes and says:
~~ Name/Craimant
On or about 29-Nov-2020 (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 to him/her in the sum of $ 10,500.00 (3)
ie
Signed: (4)
AF
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a wetrant/check was originally issued.
and sworn to before me this 2 day of F ebruagy 20.2( .
NOyARY PUBLIC COLE WALKER
Grete Notary Public - Arizona
My commission expires: Ws My Commission Expires |
Zo2! February 5, 2021 (seal)
02/0,
W: arran t/Check Numbe '
Check Num 13010075064
Original Date of Issue 02/05/2021
of 25-Nov-2020 |
Date Is
Reason for original issue of Warrant/Check (8):
11 Payroll
For Services or Goods furnished / COVID rental payments
1 Treasurer's refund/payment
Other: / Original check was unreadable to deposit

PEORIA POLYNESIAN VILLAGE
10951 N. 9157 Avenue
Peoria, Arizona 85345
Office: Fax:
Kathryn.White
February 2, 2021
|, Kathryn White, authorize Rick Caron, Maintenance, to execute an affidavit on behalf
of Peoria Polynesian Village.
Yours truly,
Kathryn White, Park Manager
Peoria Polynesian Village

Corrections and Reconcilement - Adjustments Research
.
FARGO P.O. Box 53456
Phoenix, AZ 85072-3456
December 4, 2020
FRIENDLY VILLAGE OF LONG BEACH, LLC
NEWPORT PACIFIC CAPITAL CO. INC.
17300 RED HILL AVE STE 280
IRVINE, CA 92614-5656
Subject: Adjustment of $10,500.00 to your account ending in 7263
Reference #: A-0120400669AZ
Dear FRIENDLY VILLAGE OF LONG BEACH, LLC:
On 12/03/2020, we received your electronic deposit of $26,152.68, which included an item for
$10,500.00. We are not able to process this item due to image quality. As a result, we
deducted $10,500.00 from your account on 12/4/2020.
What you need to do
You can retrieve the original item and deposit it at any Wells Fargo store or through bank by
mail. Please do not deposit it electronically. You may also wish to check the format settings on
your equipment to ensure they meet product requirements.
Please update your records to reflect the adjustment.
Deposit date: 12/3/2020
Deposit total: $26,152.68
Item amount: $10,500.00
Amount before: $26,152.68
Amount after: $512.51
Wells Fargo Sequence Number:
Customer Sequence Number:
If you have questions, please contact your client service officer or call Treasury Management
Client Services, Monday through Friday, 4:00 am to 7:00 pm, or Saturday, 6:00 am to 4:00
pm Pacific Time. Mention reference #: A-0120400669AZ .
e Ifcalling from the U.S., Canada, or Mexico, dial 800-AT-WELLS (800-289-3557),
option 2.
e Ifcalling from a country that supports Universal International Freephone Number
(UIFN), dial the international dialing code and the UIFN phone number, which is 8000-
AT-WELLS (8000-289-3557).
Thank you. We appreciate your business.
Corrections and Reconcilement - Adjustments Research
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