STAMPED & REDACTED LIFEGUIDES PBC.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM
Date: September 27, 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 if you have any questions. Please return the approved
affidavits to my attention in the Office of Budget and Finance.

Thank you.

Re: Fund: 685 / Dept:310 —
Human Resouces /
Company: LifeGuides, PBC

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

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

STATE OF ARIZONA Note: Numbers on this form correspond to

COUNTY OF MARICOPA pen hy a sheet which is
Loins PBC (1), being first sworn, upon oath deposes and says:
On or about 09-Jun-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 is due and owing, and the applicant requests that a replacement

warrant/: im/her in the sum of $4,000.00 -(3)

Signed: ~~ \ KY | 2 (4)

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

ae AG day of Segk mber 2022.

Auta FC

NOTARY PUBLIC

BARBARA L. CHUBB

mission expires: NOTARY PUBLIC OF NEW JERSEY
_e My Commission Expires June 1, 2026

(seal)
WwW. it/Check Number
[Mort oon 3010119429
| Original Date of issue |09-Jun-2022 =
Reason for original issue of Warrant/Check oF
Cl Payroll i . -
(1) Treasurer's refund/payment D ATE __ 09 9/27 /2022
© Other: i yy
GR Auanit BOARD OF

MARICOPA COUNTY