STAMPED & REDACTED TOWN OF WICKENBURG.PDF

MARICOPA COUNTY

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

INTEROFFICE MEMORANDUM

Date: September 29, 2022
To: Clerk of the Board
From: Marcia J. Bulanda

Office of Budget and Finance

Subject: Affidavit - TOWN OF WICKENBURG

Please find attached 1 Affidavit for a lost warrant to be included on the next available

Board Agenda.
e 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 232 - D640 TRANSPORTATION — GAX1D 23*4661
UTILITY/WATER — ACCOUNT NUMBER 99.00005.00

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit / Clair: Form

This application is for: Duplicate or ("] 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

pade 2 of this form.
TOWN OF WICKENBURG (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 29-Aug-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 destrayed and there is
no reasonable probability of its being found or presented for payment, ar 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/cheldk/be issued t hiti/her in the sum of $108.50 (3)
Signed: (Mo Min (4)

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

(5) Subscribed and sworn to before me this_X uth day of S eotewber 20 9.2,
i
NOTARY PUBLIC

AMY BROWN —
Notary Public, State of Arizona
Maricopa County
Commission # 696310
My Commission Expires
February 01, 2025 (seal)

My commission expires:
2/4/2625

Cae eek aera savas
Warrant/Check Number
fe reck Nu 3010125572
Original Date of Issue
(if known) (7) 29 ~-Aug -2022

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

1 Payroll 10/04/2022

() For Services or Goods furnished Wy
Uanilal jl A

0) Treasurer's refund/payment C oaks J

Other: / original check presumed lost in the mail

FUND 232 - D640 TRANSPORTATION - GAX1D 23*4661
UTILITYAWATER - ACCOUNT NUMBER 99.00605,00

TOWN OF WICKENBURG

September 26, 2022

|, Stephanie Wojcik, authorize, Stacey Canary, Senior Accountant, to execute an
affidavit on behalf of the Town of Wickenburg.

Yours truly,

Boo ke

sicohonte ojcik

Finance Director

COUNTY EXPENSE WARRANT

One Hundred Eight And 50/100 Dollars

PAY TO THE ORDER OF

TOWN OF WICKENBURG

For Questions -

or email

MARICOPA COUNTY DEPARTMENT OF FINANCE

TREASURER OF MARICOPA COUNTY

PHOENIX, ARIZONA

WARRANT NUMBER

3010125572
DATE
8-29-2022 91-2/1224
$108.50
AMOUNT
Void After
365 Days

NOT NEGOTIABLE

RETAIN THIS FOR | PAYEE

YOUR RECORDS

WARRANT NO. | WARRANT DATE | WARRANT AMOUNT

TOWN OF WICKENBURG 3910125572 08/29/2022 $108.50
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
9900005000922 99.00005.00 GAX1D 0640 230000004661 108.50

230000004661