SIGNED CECILIA MILLER FOR 021021 AGENDA.PDF

MARICOPA COUNTY Bi aay 2} a
Office of Budget and Finance
301 West Jefferson Street , Ste 966! DEC 30 ANI: 40
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 30, 2020
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 : CECILIA M MILLER

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
paae 2 of this form.
CECILIA M MILLER (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 96-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
be issued to him/her in the sum of $4, 500.00 (3)
warrant/check
WAG (4)
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 QS day of M&-emler 2020.
NOYARY PUBLIC San visage ene
My commission expires: SY “Commission No. 576285
Novemae | 2023 = (seal)
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———————————————————————————————————————————————————————————— oo ooo oo
Warrant/Check Number
3010068815
oleae
Original Date of Issue
06-Oct-2020 01/11/2021
(if known) (7)
Reason for original issue of Warrant/Check (8):
[1 Payroll
ral For Services or Goods furnished / COVID rental payments
C1 Treasurer's refund/payment
Other: / Original check presumed lost