STAMPED & REDACTED - DAVID CHASTAIN.PDF

MARICOPA COUNTY
Department of Finance

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: November 14, 2022
To: Clerk of the Board
From: Walter Chang

Department of 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 The attached 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 if you have any questions. Please return the approved

Affidavits to my attention in the Department of Finance, Ninth Floor.

Thank you.

Re: Fund: 766 / Dept:180 -
OBF / Company : DAVID
CHASTAIN

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

This application is for: Duplicate or J state-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

paae 2 of this form.
DAVID CHASTAIN (1), being first sworn, upon oath deposes and says:
Name/Claimant

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 $ 179.51 .G)

Signed: AD Ob Bees (4)

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

(5) Subscribed and sworn to before me this _ arr day of __* \ 20.4%
NOTARY PUBLIC
YOLANDA GARCIA
os . . 2 Notary Public - Arizona
My commission expires: Le) eon,
ADyiL 2] LADAD SRE” say Comm. Expires Anr 27, 2025 (seal)
Warrant/Check Number
(if known) (6) 3010127927
Original Date of Issue
(if known) (7) 23-Sep-2022 11/16/2022

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

O Payroll

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

O Treasurer's refund/payment
Other: / check presumed lost / fund : 766 / GAX 23*237