STAMPED & REDACTED - CONNOR OBRIEN.PDF

v
MAR) COPA
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: 1-31-2025

Subject: Affidavit — Replacement of Lost Warrant

Please find attached one Affidavit for a lost 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.

e The original warrant is presumed lost.

Please call Walter Chang at 506-8747 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: 219 / D190 - County Attorney / vendor name : Connor Obrien

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit /Ciaim Form

This application is for: X Duplicate or [_] State-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Connor Obrien (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/6/24  (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 affirrns that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement

warrant/check be issued to him/her in the sum of $ $1,012.24 (3)

Signed: (4 /U EZ _____(4)
Print name: (required) CON en Faariteal

Note, P/ease attach a copy of the warrant/check if available and/or any other
evidence that a warrantl/check was originally issued.

(5) Subscribed and sworn to before me this _{ 4 A, day of Nona A 20_35.

MMe tpt UAL

ra)
NOTARY PUBLIC VERONICA RAZO
Notary Public - State of Arizona
My commission express Commcoon 8 640002
LOL (4 136 Expires December 14, 2028 (seal)
Warrant/Check Number
Cif known) (6) 000003010198480
Original Date of Issue .
(if known) (7) 11/22/24
1/31/25

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

O For Services or Goods furnished
O1 Treasurer's refund/payment

X Other: Waaqe Loss VC2054295-1 Req #2- never received check

S:\VICTIM\COMP\Affidavit\Duplicate or Stale Dated Warrant Affidavit-Claim Form.doc
Revised 100518 ARS, 11-632 & 11-644

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER

PHOENIX, ARIZONA 3010198480
DATE
| aia 91-2/1221

One Thousand Twelve And 24/100 Dollars

$1,012.24
PAY TO THE ORDER OF AMOUNT
Connor Obrien
Void Afier
365 Days
NOT NEGOTIABLE

For Questions - 602-506-1379 or cmail AP@MAIL.MARICOPA.GOV
MARICOPA COUNTY DEPARTMENT OF FINANCE

RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT

YOUR RECORDS
i 3010198480 11/22/2024 $1,012.24

VICTIM WITNESS
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT

GAXIF D190 250000012219 1,012.24

00000071775K 2054295-1-rqst2
2500000142219