SIGNED AHMED KASHIF MAJID RAJPUT FOR 021021 AGENDA.PDF

MARICOPA COUNTY poanc cr surceyisor's = MW
Office of Budget and Finance = MARIS At Hea
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301 West Jefferson Street Ste 969; jay—-5 anti:s5s
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Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: January 5, 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 Department of Finance, Suite 960.
Thank you.
Re: Fund: 200 /Dept:220—Human Services Dept. / Company : AHMED KASHIF MAJID
RAJPUT

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: Duplicate or LJ 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
paqe 2 of this form.
AHMED KASHIF MAJID RAJPUT (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 07-Dec-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 be issued to him/her in the sum of $ 4,900.00 (3)
Signed: (4)
— su MINS AY
Note. Pleas—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_@0___day of Deunber 20 20.
7
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NOTARY PUBLIC
|
<s8E Re, CHRISTOPHER TROY ROMERO
Keo Notary Public - State of Arizona
My commission _ expires: . 2): MARICOPA COUNTY,
Se, YMbtY _O ) QOL OSS i” Expires ommissio! September 02, 2024 (seal)
Warrant/Check Number
3010076497
(if known) (6)
Original Date of Issue
07-Dec-2020
(i known) (7)
Reason for original issue of Warrant/Check (8):
LJ Payroll
COVID-related rental assistance
For Services or Goods furnished
11 Treasurer’s refund/payment
Presumed lost
Other:
01/11/2021

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