Extracted text (via ocr_local)
3545 characters
Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: (] Duplicate or x Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. RAAT SHivRat (1), being first sworn, upon oath deposes and says: Name/Claimant On or about TIAN vAex I), 209) (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 shown is due and owing, and the applicant requests that a replacement warrant/check he to him/her in the sum of $4- 4-5 , 78 (3) Signed: MArs ; (4) Print name: (required) SH\VRAT Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this __/7 day of Eelvul ary 20 22, NOTARY PUBLIC S— My commission expires: DANIELLE BONILLA Notary Public - State of Arizona MARICOPA.COUNTY Commission #610652 4 | 21|2027s Expires July 27, 2025 (seal) tT T Warrant/Check Number (if known) (6) G 19 404 Original Date of Issue g (if known) (7) JAWoarry Il, 20Q\ Reason for original issue of Warrant/Check (8): QO Payroll UO) For Services or Goods furnished Xl Treasurer's refund/payment O Other: S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised 100518 A.R.S. 11-632 & 11-644 2-37. 262% No whown iF avery CoV he chode war dak Oo pur ow arse rady > ovew GT torneo Coul mob aie Te chocle Wecaumt A CONID Ww ky damly . Sway we wov'vet Th check ak the 2nd a En 2020. Leon valuile the check bool expired . Try fe Wore Wt chock wermutd dow Wowk Yr. RaaAyT ShIVen Ts MARICOPA COUNTY TREASURER JOHN M. ALLEN, COUNTY TREASURER SERVICING BANK ACCOUNT 919409 Vendor : OneTime0022285, RAAJ SHIVRAJ Invoice number Invoice date Description Payment amount 2021000250 1/11/2021 PHASE #2018-0355; PARCEL #303-43-695 ; RES #16819 445.78 445.78 Total MARICOPA COUNTY TREASURER rr 919409 Y JOHN M. ALLEN, COUNTY TREASURER ACH RIF 122100024 4 SERVICING BANK ACCOUNT 91-2/1224 DATE 3 January 11 2021 2 Four Hundred Forty Five Dollars and 78/100 $445.78 2 CHECK VOID AFTER 365 DAYS 6 a oe eee ees MARICOPA COUNTY TREASURER JOHN M. ALLEN, COUNTY TREASURER pa At ee AUTHORIZED SIGNATURE a8 Hog |_Security Features Included. ent "+ om 301 West Jefferson St., Rm. 100 Phoenix, Arizona 85003 Phone: (602) 506-8511 * Fax: (602) 506-1102 Maricopa County http://treasurer.maricopa.gov Treasurer January 6, 2021 RAAJ SHIVRAJ Subject: Parcel Number: 303-43-695 6 Resolution Number: 16819 Dear Taxpayer: We have been notified by the Maricopa County Assessor's Office that a tax resolution has been approved, adjusting the tax liability on the above-captioned parcel for the 2018 tax year. This has resulted in an overpayment in the amount of $445.78. Enclosed you will find your refund in the amount of $445.78. Should you have any questions regarding this notice, please contact our office at (602) 506-8511. Resolution Section Enclosure For office use only: BTX REFUND 2018.355.16819.23