STAMPED & REDACTED - ARIZONA LIONS VISION CENTER INC.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM
Date: November 21, 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: 255 / Dept: 800—-
Superior Court / Company
: Arizona Lions Vision
Center Inc

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

This application is for: Duplicate or O 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
paae 2 of this form.

Arizona Lions Vision Center Inc (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 14-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/c Aue to im/her | in the sum of ¢ 245. 00 (3)

MW TW (4)

? _ 1 E day of WWM 20.32.

(5) Subscribed and sworn to before me this

Cb ne _lrhalstE

NOTARY PUBLIC

My commission expires: A anlog 15,3034

EDNA RICHARDSON
Public - State of Arizona
MARICOPA COUNTY,
Commission # 576644
Expires January 15, 2024

Warrant/Check Number 3010127046

— (if known) (6)
Original Date of Issue 1 4-Sep-2022 11/22/2022

(if known) (7)

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

0 Payroll

For Services or Goods furnished / Eye Glasses Including Sunglasses (Including Frames, Cases,

4
© Treasurer's refund/payment
Other: / check presumed lost / fund : 255

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY

WARRANT NUMBER

PHOENIX, ARIZONA 3010127046
DATE
09-14-2022 94-2/4224
Two Hundred Forty Five And 00/100 Dollars
$245.00
PAY TO THE ORDER OF AMOUNT
Arizona Lions Vision Center, Inc.
Void After
365 Days
For Questions - or email NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
Arizona Lions Vision Center, Inc. 3010127046 09/14/2022 $245.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
426 Optician/Optometrically Services PN3 D270 230000000243 | 230000007696 245.00

Arizona Lions Vision & Hearing Foundation

Invoice

3124 E Roosevelt St. Date Imoice #
Phoenix, AZ 85008
8/31/2022 426
Bill To Ship To
Admin Services-Finance Maricopa County Superior Court
Juvenile Travel and Court Travel
201 W Jefferson,CCB-4th Floor Phoenix,AZ
P.O. Number Terms Rep Ship Via F.0.B. Project
199129 8/31/2022
Quantity Item Code Description Price Each Amount
1] Glasses SV Coryeion Dunning 35.00 35.00
1] Glasses SV Andrew Perez 35.00 35.00
1] Glasses SV Eloria Vasquez 35.00 35.00
1] Glasses SV Aiby Galvez 35.00 35.00
1] Glasses SV Nikole Mcfarland 35.00 35.00
1} Glasses SV Jelen Ashton 35.00 35.00
1] Glasses SV Ethan Henry 35.00 35.00
Total $245.00

Arizona Lions Vision & Hearing Foundation
3124 E Roosevelt St.
Phoenix, AZ 85008

Received From:

Maricopa County Superior Court

Admin Services-Finance

Juvenile Travel and Court Travel

201 W Jefferson,CCB-4th Floor Phoenix,AZ

‘Date Received 08/31/2022

 Checl/Ref. No. 5560

Invoices Paid

Payment Receipt

Date Number Amount Applied
02/28/2022 379 -$70.00
03/31/2022 385 -$70.00
04/30/2022 392 -$140.00
05/31/2022 398 -$175.00
06/30/2022 414 -$70.00
07/31/2022 419 -$280.00

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