STAMPED AND REDACTED 3010218641 - CITY OF GOODYEAR FINANCE DEPT.PDF

MARICOPA
COUNTY

Office of Budget & Finance
301 W. Jefferson St., 9" Floor
Phoenix, Arizona 85003

P: 602-506-3561
F: 602-506-4451

Maricopa.gov

To: Clerk of the Board

From: — Office of Budget & Finance, Accounts Payable

Date: 12.09.25

Subject: Affidavit - CITY OF GOODYEAR FINANCE DEPARTMENT

Please find attached one Affidavit for a Stale Dated warrant to be included on the
next available Board Agenda.

® The attached item has been researched to ensure the warrant in question has not
been cashed or previously re-issued.

» The original warrant is presumed lost.

Please call Marcia Anderson 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: FUND 222 —- D220 HUMAN SERVICES ~ GAX1D 26*1512 — FY26 07.30.25 CITY OF GOODYEAR
~ UTILITY ASSISTANCE

\
MA RI COPA Application for a Duplicate or Stale Dated

COUNTY Warrant/Check Affidavit/Claim Form
This application is for lv] Duplicate or J Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond te the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form

CITY OF GOODYEAR FINANCE DEPARTMENT (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 31-JULY-2025 (date) (2) a warrant/check was issued to the above named
person/entity in the amount 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 issues to him/her in the sum of $584.26 . (3)

(4)

Print Name: (required) a} eVWYIZ.
Note: Please attach a copy of the warrant/check if available and/or any other evidence that a
warrant/check was originally issued.

as “Ach Nolary Public - Stale of Arizona
My commission expires: : 3 f4ARICOPA COUNTY
~ SS Comunission # 640838
I-A + 2P Hho THE” eypnes Novernbar 6, 2026 (seal)

WarrantGheckNumber 13010218641

Original Date of } ,
se imeem) 31-JULY-2025

12/17/25

Reason for original issue of Warrant/Check (8):
0 Payroll
(1 For Services of Goods furnished

1 Treasurer's refund/payment
Other: FUND222- D220 HUMAN SERVICES GAX1D 26°1512 - FY26.07.30.25 CITY OF GOODYEAR - UTILITY ASSISTANCE

S\PROCESSES\Warrants - Duplicate or Stale\02Z Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised
100818

ARS. 11-632 & 14-644

DZ

Goodyear

December 9, 2025

|, Jessica Archuleta, hereby authorize Jocelyn Boehme, Customer Service Supervisor, to
execute and sign an affidavit on behalf of the City of Gaodyear.

Jessica Archuleta

Senior Analyst
Finance Department

Finance Department

www goody earaz,20v

Warrant Number —————--—- ren

ae \

Status —

\c. Suppertina Bade fOpitenaly —-= =