LISERVIS LLC.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
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Date: March 13, 2019 32.•
C
To: Clerk of the Board
From: Walter Chang
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached 1 Affidavits for lost warrants to be included on the next
Board Agenda. available
• The attached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.
• 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: Treasurer-D430 / Company : LISERVIS

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or 51 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.
LISERVIS LLC (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11-Jul-2017 (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 ued to him/her in the sum of $ 1,641.15 .(3)
Signed:
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Sullsc - rx4}1 to before me this day of 07 FEB 2019 20
Aaron C. Easlic*
Vice Consul of the
TAR United States of America
My commission expires: MY COMMISSION DOES NOT EXPIRE
(seal)
i=MBASSY HE UNITED STATES OF AMERIO<‘
Warrant/Check Number 860681 IAN
(if known) (6)
Original Date of Issue 11-Jul-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
ID Payroll
D For Services or Goods furnished
Li Treasurer's refund/payment
Other: check presumed lost

L1SERVIS LLC
A Better Miles For Opportunities
, Manager of Yevgeniya Rybakova - Yevgeniya Rybakova, authorize Yevgeniya Rybakova
to execute an affidavit for LISERVIS LLC
Yours truly,
Manager of Yevgeniya Rybakova - Yevgeniya Rybakova
Operating manager
9 East Loockerman Street, Suite 202 Dover, Delaware
DE 19901
302-480-9393
auction.liservis@gmail.com