STAMPED & REDACTED - MARK FERNANDEZ.PDF
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v MAR) COPA COUNTY Office of Budget & Finance To: Clerk of the Board 301 W. Jefferson St, 9*Floor From: Office of Budget & Finance, Accounts Payable Phoenix, Arizona 85003 Date: 1-15-2025 Subject: Affidavit — Replacement of Lost Warrant P: 602-506-3561 F: 602-506-4451 Please find attached one Affidavit for a lost warrant to be included on the next Maricopa.gov 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 : Mark Fernandez Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/ Claim Form This application is for: Duplicate or CJ Stale-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. Mark Fernandez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 4/18/2024 (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 payiss ed ifn/her in the sum of g4.77 .(3) Signed: vas 4 4 Cg (4) Print name: (required) MATIC S: Bn Aanne2 Note: Alease attach a copy of the warrant/check if available and/or any other evidence that a warranl/check Was originally issued. (3) Subscribed nd rom to \efore me this‘ | day of a Wa ay 202), Wk a Nid AAA OTARY PUBLIC i aaieaieree) expire res. | (seal) Warrant/Check Number [Check Nu 00000307 0179689 Original Date of Issue 32 it known) (7) 4/18/2024 Reason for original issue of Warrant/Check (8): ’ 1/16/25 O Payroll - 4 For Services or Goods furnished OO Treasurer’s refund/payment other: Victim Compensation: 1945111-1-rqst10 S:\PROCESSES\Warrants - Duplicate or Stale\O2 Forms\Current Claim Form\t00518 Warrants Checks notice of claim.doc Revised 100518 A.R.S. 11-632 & 11-644 counryexpense warrant TREASURER OF MARICOPA COUNTY PHOENIX, ARIZONA Four And 77/100 Dollars PAY TO THE ORDER OF Mark Fernandez For Questions - 602-506-1379 or cmail AP@MAIL.MARICOPA.GOV MARICOPA COUNTY DEPARTMENT OF FINANCE DATE WARRANT NUMBER 3010179689 . Void After 365 Days $4.77 AMOUNT NOT NEGOTIABLE RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE WARRANT AMOUNT YOUR RECORDS VICTIM WITNESS 3010179689 04/18/2024 $4.77 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT 00000069779K 1945111-1-rqst10 GAXIF D190 240000022879 4.77 240000022879 CA