STAMPED & REDACTED - FOR AGENDA ATTACHMENT - TIM WRIGHT.PDF

MARICOPA
COUNTY
Office of Budget & Finance To: Clerk of the Board
301 W. Jefferson St., 9 Floor -
From: — Offfce of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003
Date: 01.10.24
Subject: Affidavit,— Tim Wright
P: 602-506-3561
F: 602-506-4457
Please find attached one Affidavit for a duplicate warrant to be included on the next
Maricopa.gov 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 is presumed lost.
Please call Marcia Bulanda at 506-7291 if you have any questions. Please return the
approved Affidavit to my attention in the Office of Budget and Finance, 9" Floor.
Thank you.
Re: D220 Human Services~ Fund 222—-GAX1D 24*9082- Keene, Evan ~ Rental Assistance

Application for a Duplicate or State-Dated Warrant/Check
Affidavit/ Claim Form
This application is for: V1} Duplicate or [1 State-Dated are on 2)
(definitions page
sspondto
STATE OF ARIZONA Note: Numbers on this ‘form ‘cortespand to i
COUNTY OF MARICOPA pane instruction sheet which is |
1 page 2 2 of oft this i form.
TIM WRIGHT Sarees
(1), being first sworn, upon oath deposes and says:
NamelCisynanl
On or about 22-Nov-2023 (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 the sum of $1,865.00 (3):
oes
Signed: == (4)
Nate, Please attach a copy of the warrant/check if available any other
and/or
evidence that 4 warrant/check was originally. issued.
th Ton 14
(5) Subscribed and swom to before me this la “day of 20 4
ANTHONY AVELAR ;
GP i Notary Public Arizona
My B}__aticana County
A amin ex a
SH” My Comm, Expires Mar $, 2027 {seal}
=T
‘Warrant/Check Number ;
301 01 66803
(if known} (6) ; ee
| Original Date of Issue .
ee 7 Nov-2023
(if known) (7) a 1/11/2024
Reason for original issue of Warrant/Check (8);
[1 Payroll
Cl] For Services or Goods furnished
( Treasurer's refund/payment _
0220 HUMAN SERVICES - FUND 222 - GAX10 2450) 3082 - KEENE, EVA N - RENTAL ASSISTANCE
4 Other: —

TREASURER OF MARICOPA COUNTY WARRANT NUMBER
PHOENIX, ARIZONA 3010166803
DATE
> f)>
One Thousand Eight Hundred Sixty Five And 00/100 Dollars
$1,865.00
PAY TO THE ORDER OF
TIM WRIGHT AMOUNT
Void After
365 Days
For Questions - 602-506-1379 or email AP@MAIL-MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT. OF FINANCE
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRA NT DATE TE | LW WARRANT AMOUNT
OUR RECORDS
TIM WRIGHT 3010166803 11/22/2023 $1,865.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
INV-0000623047 KEENE, EVAN - RENTAL ASSISTANCE GAX1D D220 240000009082 4 865.06
240000009082

Warrant n, Issued date Paid date Amour
lssuect S1O16R803 11227023 DO:OG am
12
Warrant number: JUG e6852
Amount Payee oe] count
I ox my TIRA WRIGHT