ROGER FLORES 101919 SDW FOR 021021 AGENDA.PDF

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MARICOPA COUNTY Le CARD d SUP et ieoae heen
Office of Budget and Finance Pa Ci Y paved
301 West Jefferson Street , Ste 960 202) Jay
“5 AM II: 55
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: 100 /Dept:430- Treasurer / Company : Roger Flores

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: Duplicate or CJ 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.
Roger Flores (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 14-Oct-2019 (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 im/her in the sum of $9,858.70 (3)
P (4)
[7
che Piésss attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
re
5) Subscribed and sworn to before me this day of 20
NOTARY PUBLIC =
My commission expires:
Warrant/Check Number ~~
896499
(if known) (6) ~N
Original Date of Issue ™
Reason for original issue of Warrant/Check (8):
O1 Payroll
© For Services or Goods furnished
Treasurer's refund/payment
Original check presumed lost in the mail
Other:

CALIFORNIA JURAT WITH AFFIANT eth oll Se CODE §
Sasa cate
SERRE
[See Attached Document (Notary to cross out lines 1-6 below)
C1 See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary)
Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of Subscribed and sworn to (or affirmed) before me
Sexe to
County of QDACLaAWLNWN
on this 30 day of Decem kaa 2029,
,
Date Month Year
by
Rog er Flores
(1)
CHRISTY ANDREI-MOORE (and (2) XM LA- ),
Notary Public - California
Names) of Signer(s)~
Sacramento County Z
Commission # 2186198 =
My Comm. Expires Mar 11, 2021 f proved to me on the basis of satisfactory evidence
a
to be the person(s) who appeared b me.
Signature
Signature of Notary Public
Seal.
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document tel Dated WarTran tfeback
ys a
Title or Type of Document /fyjali late Oifern Duh Cade Of cument Date: (2-30 2Zozo
Number of Pages: _ } Other Than Named Above:
SENS t i
= v
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