STAMPED & REDACTED- AZ SECRETARY OF STATE HAVA DIVISION .PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson, 9"" Floor
Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM
Date: October 21, 2022
To: Clerk of the Board
From: Marcia J. Bulanda

Office of Budget and Finance

Subject: Affidavit -AZ SECRETARY OF STATE HAVA DIVISION

Please find attached 1 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 lost.

Please call me at 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 222 —- D220 HUMAN SERVICES — GAX1D 23*2089
ANGELICA ARREDONDO NOTARY APPLICATION FEE

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Duplicate or [7] state-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA heliaeier she frstuction sheet which is

AZ SECRETARY OF STATE HAVA DIVISION (1) being first sworn, upon oath deposes and says:
NemerClannant

On or about 93-Aug-2022 (date)(2) @ 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 nat
presented for payment within one year after the date of issuance.

Therefore, under penalty of perjury, claimant hereby affirms that this daim is correct
and the amount shown is due and owing, and the applicant requests that a replacement

wee RC RAO aan of $43.00 . (3)

Signed: \ \ ) (4)

Note; Please atlach a copy of he warrant/chack_if available and/or any other
. - . Stata ol Ames cue
evidence that a warrant/check was originally issued. Cente of Wer cope

\ “
L

(5) Subscribed ey to before me this (3) dayof_Dhwrec 2052.

NOTARY’PUBLIC

DOLORES NAVARRO
Notary Public, State of Arizona’
Maricopa County
Commission # 622618
My Commission Expires (seal)

March 01, 2026

eens SOLKMHSER_3010123767
rigina Dat ® of ae 03-Aug-2022

My commission expires:
latett J. By

Reason for original issue of Warrant/Check (8):
OF Payroll 11/01/2022
0 For Services or Goods furnished

CO Treasurer's refund/payment
Other: / Original check presumed lost in the mail

FUND 222 - D220 HUMAN SERVICES - GAX4D 232089
ANGELICA ARREDONDO NOTARY APPLICATION FEE

SECRETARY OF STATE
State of Arizona

October 20, 2022

Maricopa County
Department of Finance
Attn: Marcia Bulanda

Re: Affidavit/claim for check #3010123767
Dear Ms. Bulanda

I Patricia Viverto authorize Diana Ogaz, Notary Supervisor, to execute an affidavit on
behalf of Arizona Sceretary of State, Business Services Division.

Sincerely,

Patricia A. Viverto
Director of Business Services

COUNTY, EXPENSE: WARRANT

TREASURER OF MARICOPA COUNTY WARRANT NUMBER

PHOENIX, ARIZONA 3010123767
DATE
8-03-2022 94-2/1224
Forty Three And 00/100 Dollars
$43.00

PAY TO THE ORDER OF
AZ SECRETARY OF STATE SVOUNT
HAVA DIVISION ‘Tot Stier

365 Days

For Questions -

or email

MARICOPA COUNTY DEPARTMENT OF FINANCE.

NOT NEGOTIABLE

WARRANT NO. | WARRANT DATE | WARRANT AMOUNT

RETAIN THIS FOR | PAYEE.
YOUR RECORDS
AZ SECRETARY OF STATE 3010123767 08/03/2022 $43.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO, AMOUNT
ANGELICA ARREDONDO NOTARY APPLICATIC | GAX1D D220 230000002089 43.00

ADMIN-23-023

230000002089