SIGNED JOSE S MORALES.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
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INTEROFFICE MEMORANDUM =2
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Date: January 29, 2021 =
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To: Clerk of the Board nh >
From: Beth Brown ey
Department of Finance S
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Subject: Affidavit - Replacement of Lost Warrant
Please find attached affidavit for lost warrant to be included on the next available Board
Agenda.
e The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.
e The original warrant has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Jose S Morales
Dept 220
Fund 200

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
paae 2 of this form.
JOSE S MORALES (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 17-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 $ 15,000.00 .(3)
D.ovle—
Signed: Liab (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 pe, 7) day of Joun 20.2 [ .
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NOTARY PUBLIC VIOLET YANEZ
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ision es: : ssion No. 574548
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Warrant/Check Number
3010077691
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Original Date of Issue
Reason for original issue of Warrant/Check (8):
OO Payroll
COVID Rental Assistance Payment
For Services or Goods furnished
(C1 Treasurer's refund/payment
01/29/2021
C1 Other: ;

Request for Taxpayer Give Form to ins
W-§
Form Certification requester. Do not
Identification Number and
(Rev. October 2018) send to the IAS.
Department of tha Treasury Instructions and the latest Information.
Internal Revenua Service > Go to www.ire.gov/FormW? for
T Namo (as shown on your Income tax retum). Name Is required on this line; do not leave this line blank,
Jose S Morales
2 Business name/disregarded entity name, Hf ditferent from above
1. 4 Exemptions (codes apply only to
3 heck appropriate box Tor federal tax classification of the porson whose namo is entered on line Check only one of the certain entitles, not Individuals; see
page following seven boxes. instructions on page 3);
C1 Cscomportion 1 Partnership C1 thstlestate
on PA Individualisole proprietoror G corporation . (if any)
Exompt payes code
single-member LLG
type. [7] United nattity company. Enter the tnx classification (C=C corporatlon, SS corp lon, P=F hip) >
Print Instructions 8loter Check the apprapriate box In the lina above for the tax classification of the single-member owner, Do nat check Exemption drom FATCA reporling
or single-membor LLG that Is disregarded from the ownor unless the owner of the LLC {s
LLG if the LLC is classified as a i Othervise, a sligle bar LLC that
another LLG that Is not disregarded from the ownor for U.S, fecteral tax p P
is disregardad from the awner should check the appropriate box for tho tax classification of Its owner.
Aggies to accounts msinisined ovis tha US)
Specific (71_ Other (9e8 instructions) Requastor’s name and address (optional)
B Addmss (number, streat, and apt, or sulte no.) See Instructions.
2225 N 91st Glen ‘
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6 Gity, state, and ZIP code
Phoenlx, AZ 85037
7 Ust int 201{3) here (oF
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box, The TIN provided must match the name given on iine 4 to avoid Social
backup withholding. For individuals, this Is generally your socal security number (SEN). However, for a
resident ellen, sole proprietor, or disregarded entity, see the Instructions for Past |, later. For other
entities, it is your emptoyer identification number (EIN). If you do not have a number, see How to gel a
TIN, tater.
1. Employer kdentification number
Note: ff the account fs in more than one name, see the instructions for ine Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.