STAMPED & REDACTED - VESNA DJUROVIC.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM
Date: November 8, 2022
To: Clerk of the Board

From: Walter Chang
Office of Budget and Finance

Subject: Affidavits - Replacement of Lost Warrants

Please find attached 1 Affidavits for lost warrants to be included on the next available

Board Agenda.
e Theattached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.

e The original warrants have a void/stale date/stop payment done.

Please call me at 506-8747 if you have any questions. Please return the approved
affidavits to my attention in the Office of Budget and Finance.

Thank you.

Re:  Fund:766 / Dept: 180-
OBF/ Company: Vesna
Djurovic

Application for a Duplicate or Stale-Dated Warrant/ Check fo

Affidavit/Claim Form

This application is for: Duplicate or L] Stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
paqe 2 of this form.
VESNA DJUROVIC (1), being first sworn, upon oath deposes and says:
On or about 23-Sep-2022 (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 issued to him/her in the sum of $ 143.08 (3)

Signed: \o (Daw nu, (4)

Note: Please attach a copy of th@ warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

(3) Subscribed and sworn to before me this vin day of _Alorynbte 20_22.,

Nats. %). hi Ane fs
NOTARY PUBLIC ia

» DARYL. “A. DE ANGELO
Notary Public - State of Arizona
MARIG OPA COUNTY
Commission # 563232
Expires May 14, 2023 (seal)

My commission expires:
Mave ff, 203%

Warrant/Check Number 3010128939

(if known) (6)

Original Date of Issue
(if known) (7) 23-Sep-2022 11/08/2022

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

C1 Payroll

For Services or Goods furnished / PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022

 Treasurer’s refund/payment
Other: / check presumed lost / fund : 766 / GAX 23*351