REDACTED - FOR AGENDA ATTACHMENT - DEAN FOLK AND ROBIN KELIPULEOLE #1029041.PDF

l
MARICOPA COUNTY

John M. Allen, Treasurer
301 West Jefferson St., Rm. 100
Phoenix, Arizona 85003

Phone: (602) 506-8511

http://treasurer.maricopa.gov
TREASURER’S OFFICE
To: Clerk of the Board
clerk.agenda@maricopa.gov
Dorene.Stretar@Maricopa.Gov
From: Treasurer's Office
Katelyn Hale
katelyn.hale@maricopa.gov
602-506-3357
Cathy Sanchez 7]
cathy.sanchez@maricopa.gov
602-506-7881
Re: Stale Dated Warrant
Name Warrant Amount | Dept/School
No
FOLK DEAN/KELIPULEOLE ROBIN L 1029041 $40.77 | Treasurer

F
MA R) COPA Application for a Duplicate or Stale Dated

COUNTY 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 the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form
_DEAN wall Robin) KEV Puce fteing first swron, upon oath deposes and says:

Name/

ima
On or about Blea (date) (2) a warrant/check was issued to the above named

person/entity irf thé 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 Pe applicant requests that a replacement warrant/check
$

be issues to him/her in the sup 40.1 | _. (3)
send We! h LH

Print Name: (required) LA, 3
Note: Please attach a copy of the warrant/check if available and/or any other evidence that a
warrant/check was originally issues.

ty

NOTARY PUBLIC

[me re ee or reer
DANALYNN PETRUCELLI
otary Public - State of Arizona

MARICOPA COUNT
Commission # 633203
Expires July 27, 2026

My commission expires:

O07— 27-202
Warrant/Check Numb
erences" | 102304

(seal)

Original Date of Issue .
(if known) (7) B/S [26 24.

Reason for original issue of Warrant/Check (8):
O Payroll

O For Services or Goods furnished

bi Treasurer's refund/payment
1 other: [AX Case NO. TK 2aiG-QnO Rey

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

VON
ARS. 11-632 & 11-644 KY 9123)25

[ 164-28-077 2 = x
File Help
Yeat_| Description [ActDate | TranNum Amount | Images _| PmtDate | Half Code | A
2017 TAX PAYMENT 2024-0917 RS 27211 $1,86292 N 2018-04-30 F 6:
2017 TAX PAYMENT 2024-0917 AS27211 $2,027.30 N 2017-10-30 F &
2017 POST NEW TAX(RESOLUTION) 2024-0917 RS 27211 $3,390.22 N & |
2017 CANCEL TAX 2024-0817 RS -27211 $4,05460 N 6
2017 RESTORE TAX 2024-0917 RS -27211 $2,027.30 N 1 &
2017 RESTORE TAX 2024-09-17 RS -27211 $2,027.30 N F &
2024 INFO STATEMENT 2024-08-25 N 1
2024 TAXBILL 2024.08.24 Y 1
2016 REFUND 2024-08-08 $40.77 N 1
Parcel #: [164-28-077 Activity: REFUND Act Date ‘08/08/24
Tax Year: [2016 Tran#[ - Act Time/i2:00 AM
Activiy Detal | Addess Detail |
CP H: jo Check Date: 0s708/24
Buyer #: [0 Check #: [1029041
Fund: [26 Refund Amount: I $40.77
0S. Refund ID 2024068583 RESOLUTION = Oo x
File Help
4i2)
RefundAmount — |$40.77 Requester; [RESOLUTIONS on 8/6/2024
Refund Reason: [Resolution has reduced taxes Status: [DISBURSED on 8/6/2024
Slip 1D; 202400708
Address: [FOLK DEAN/KELIIPULEOLE ROBIN L Check Request: [QASIMYAR GROUP

Impounds | Stub | Comments |

Reference #: [RES # 02896

Source Fund | Linked |
033 True

Amount | Tax Year_| Status
$40.77 2016 READ‘

Impound Total : 1

Impound #1
Pacel/Rol :|164-28-077 Dest fund :|026
cp#: [0 Reso#: [2896
CP buyer # :/0 Phase #: |8000
Mortgage code: [-
Transaction #; [08402057 ——~C~*~*~C~*S
Case #: [

September 9, 2025

Maricopa County Treasurer’s Office
301 W. Jefferson Street
Phoenix, AZ 85003

Dear Sir or Madam,

Enclosed is a notarized document requesting a duplicate check be issued
for a stale-dated check No.1029041issued on August 8, 2024 to resolve
Tax Case TX2016-000882 (Qasimyar vs. Maricopa County).

This check was sent to our previous address, returned and mailed to our
new address several days before it expired from the Maricopa County
Treasurers office, evidence attached.

On August 13, 2025 I filed a claim assisted by a Maricopa County
Customer Service Representative. Approximately 2 weeks later I
received a notice from Maricopa County that a notarized document was
required to secure another check.

The check is attached, evidence of the Treasurer’s office sending the
initial check to our current address just days before the check expired
and the notarized form.

Please review the attached documentation and re-issue the check.

Thank you

“bean Folk & Robin Keltinuioio te,