SIGNED BERNARDINO SEPULVEDA FOR 021021 AGENDA.PDF

MARICOPA COUNTY KRICOP A COUN
Office of Budget and Finance
1 JAN -7 PH
301 West Jefferson Street Ste 96 dt
, mye
Phoenix, Arizona 85003 d
UN
INTEROFFICE MEMORANDUM
Date: January 7, 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 : BERNARDINO SEPULVEDA

‘Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: Duplicate or L] 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.
BERNARDINO SEPULVEDA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 15-Oct-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 $ 3,000.00 (3)
Signed: éveiw el ai (ead Let ail om. (4)
f
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 uM day of don 20d0..
ac
NOTARY PUBLIC
My commission expires: ‘Notary Public = Arizona
K\-\S- 20a) Maricopa sratteal)
Y Expires.05/15/20:
Warrant/Check Number
3010070031
(if known) (6)
Original Date of Issue [|
1 5-Oct-2020 01/11/2021
(if known) (7)
Reason for original issue of Warrant/Check (8):
L] Payroll
For Services or Goods furnished_/ COVID rental payments
CL] Treasurer's refund/payment
Other: / original check presumed lost

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Ciaim 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
page 2 of this form.
BERNARDINO SEPULVEDA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 15-Oct-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 ¢ 3,000 -00 .(3)
Signed: Lerner eethiieaton (4)
Note. Please attach a copy of the warrant/check if available and/or any other
evidence that a.warrant/check was originally issued. — ; Les
(5) Subscribed and sworn to before me this 57 _ 5" ay of donuacu 20Q0.
NOTARY PUBLIC
My commission expires: *\ Notary’ Public Arlzobia
S- tp S54 MS * Maricopa Cou 7
Vo- 2001 Bd Expires 06/15/ all
War
rant/Check Number 13040070031
|
| Original riginal Date of Iss |
Date of Issue [15-Oct-2020
Reason for original issue of Warrant/Check (8):
C1 Payroll .
/ COVID rental payments
For or furished
Services Goods
r
rai Other: ~/ original check. presumed fost

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