STAMPED & REDACTED MARIA PELLUM .PDF

MARICOPA COUNTY

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

INTEROFFICE MEMORANDUM

Date: September 8, 2022
To: Clerk of the Board
From: Marcia J. Bulanda

Office of Budget and Finance

Subject: Affidavit - MARIA PELLUM

Please find attached 1 Affidavit for a duplicate 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:

FUND675-D750 RISK MANAGEMENT — GAX1D 23*2799 WC277022013310 PELLUM TPD 7/6/22-
7/19/22 - MSETTLE

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 numbers on the Instruction sheet which is
pade 2 of this form.

MARIA PELLUM (1), being first sworn, upon oath deposes and says:
Namercaimant
On or about 08-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 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 amourt shown is due and owing, and the applicant requests that a replacement

mee avy him/her in the sum of $1,583.80 (3)
Signed: : ‘ ee (4)

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

(5S) Subscribed and sworn to before me this 4 day of September. 204%_.

State of Aeveoncs,

NOTARY PUBLIC
COURTNI T!
My commission expires: Hay be Site Ara
Auquat I 2095" Commission # 611638 (seal)
v Expires August 1, 2028
Warrant/Check Number
(if known) (6) 3010124075
Original Date of Issue
{if krown) (7) 08-Aug-2022
Reason for original issue of Warrant/Check (8): - 09/08/2022
= / \ ;
O Payroll UGK aa ( yh \ K
C1 For Services or Goods furnished ‘ sed

O Treasurer’s refund/payment
Other. / original check presumed lost in the mail

FUND 675 - D750 RISK MANAGEMENT - GAX1D 23*2799
WC277022013310 PELLUM TPD 7/6/22-7/19/22 - MSETTLE

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY

PHOENIX, ARIZONA

DATE
08-08-2022
One Thousand Five Hundred Eighty Three And 80/100 Dollars
PAY TO THE ORDER OF
MARIA PELLUM
Void After
365 Days

WARRANT NUMBER
3010124075

94-2/1221

$1,583.80
AMOUNT

For Questions - or email NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE,
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
SETTLE 3010124075 08/08/2022 $1,583.80
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO, AMOUNT
808PELL WC277022013310 PELLUM TPD 7/6/22-7/419/22 |GAX1D D750 230000002799 4,583.80)PU

230000002799

PSHM ¢ FEI
TASSET CODE: Y= FINED SSSET

GAXiD DIRECT PAY-~SINGLE LINE FORM

ORIER IS
S bala S

DOCUMENT ID.

230000002 789

RECORD DATE a BULSET SINGLE vee HANDLING SCHEGULED FAY GATE
iMaeneyy | sca vee FY eao caccx | “ASSET CODE SBE enmoer ry BOCUMENT NET TOTAL
} ;
ogieees | 2023 | 23 2 PU __ Betiaba
USE TAX AROUNY FREIGHT TOTAL
VEROOR save: MSETILE |
venpor WARE) MARTA PELLUM
ADIDRESS [LINE 4h
ADDRESS [LINE 2} _ . enn
ery. srave,ne PHOENIX faz | 85003
ACCOUNT DISTRIBUTION SECTION == :
sub | q 4 HeveNue [ie SUB OBS [ eReseage | PHASED |
PUNO (Lump. DERE: 2 | MAME] APPROP ONT | meet PUR 82) SIG MEY ot A | woe. | TENCTION | yenws | PROSRME. | ppc
875 F512 4000 WADI

B426) 17

ICE SECTION

ni 808PELL WC277022013310 PELLUM 4,583.80!
exg
oy i

ce

$1,583.80

PREPARED BY,

Tracey Wright

IPLEASE PRAT AME)

DEPARTMENT APPROVAL: Samantha Bright

(SUT-CAIZED SIGNATURE:

1810-010

nate,  O809/88

MLAP OT14

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