REDACTED FOR AGENDA ATTACHMENT - ADAM AND CYNTHIA BRONFMAN.PDF

John M. Allen, Treasurer
301 West Jefferson St., Rm. 100
Phoenix, Arizona 85003

L
M A R) Cc ‘@] PA C Oo U N T Y a (602) 506-8511

TREASURER’S OFFICE

‘treasur ricopa.gov

To: — Clerk of the Board
clerk.agenda@maricopa.gov

Dorene.Stretar@Maricopa.Gov

From: Treasurer’s Office

Katelyn Hale Kit

katelyn.hale@maricopa.gov
602-506-3357

Y
Cathy Sanchez Cos

cathy.sanchez@maricopa.gov

602-506-7881

Re: Stale Dated Warrant

Name Warrant Amount Dept/School
No
ADAM BRONFMAN R/CYNTHIA G 1413250 $1,469.37 | Treasurer

l
MA R’ COPA Application for a Duplicate or Stale Dated

COUNTY Warrant/Check Affidavit/Claim Form
This application is for Duplicate or Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form
Adam Bronfman (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 9/23/24 (date) (2) a warrant/check was issued to the above named
person/entity in the amount 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 erjury, claimant hereby affirms that this claim is correct and the
amount shown is due an

wing, and ihe applicant requests that a replacement warrant/check
be issues to him/fer jn

of $1969.37 (3)

Signed: L CALM
Print name (pared ee Bronffan
Note: Pleas¢’ attach a copy of the warrant/check if available and/or any other evidence that a
warrant/check was originally issues.

—
(5) Subgcri sworn to before me this /F day of SEMTEUI th 20% _.
NOTARYRUBLIC ai

Richard Jeffers

(cm _ Notary Public
ee) ) Maricopa County, Arizona
My Comm. Expires 02-12-29

(4)

My commission expires:

62/ir/p0 27 Commissiofgésafy9149
Wi b
a ae er 1413250
Original Date of Issue
(if known) (7) 9/23/24
Reason for original issue of Warrant/Check (8):
O1 Payroll

O For Services or Goods furnished
Treasurer's refund/payment Qasimyar/APN 174-39-017
O Other:

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised

100518 P
Vertes wo

ANNO 14299044 444 w\\t

martcopa Maricopa County Treasurer's Office

COUNTY
Tmeasunens orice Check Details for Check Number: 1413250

Payee: BRONFMAN ADAM RICYNTHIA G
Issue Date: 9/23/2024
Check Amount: $1,469.37

John M. Allen

Maricopa County
Treasurer

301 W Jefferson Street,
Suite 100

Phoenix, AZ 85003-
2199

Reference Number Approved By Details Amount
CC-00636088 Refund: , QASIMYAR GROUP $1469.37
Refund: , QASIMYAR GROUP.
Total $1469.37
Date: 11/13/2025 2:52 PM Page 1 of 1