STAMPED & REDACTED - FOR AGENDA ATTACHMENT - AZ SECRETARY OF STATE.PDF

v
MAR) COPA
COUNTY

Office of Budget & Finance To: Clerk of the Board

301 W. Jefferson St, 9*Floor From: Office of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003
Date: 9-19-2024

Subject: Affidavit — Replacement of Lost Warrant
P: 602-506-3561

F: 602-506-4451

Please find attached one Affidavit for a lost warrant to be included on the next
Maricopa.gov available Board Agenda.

* 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 presumed lost.

Please call Walter Chang at 506-8747 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: 265 / D860 - Public Health / vendor name: AZ SECRETARY OF
STATE

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

This application is for: Duplicate or 1 stale-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
paae 2 of this form.

AZ SECRETARY OF STATE (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 92-Aug-2024 (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 be issued to him/her in the sum of $ 43.00 -(3)

Signed: Fro (4)

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

Vte OF Ryi2zenqg County OF Miryp top t

(5) ‘Subscribed and ve, n to before me this __{J/4_day of Spl. tales 20 Jef.

Wb ‘Leu door. : 24

NOFARY PUBLIC

My commission ex; ires:
UJd- 262:

(seal)

Warrant/Check Number
" (if known) (6) 3010189366

Original Date of Issue
(if known) (7) 02-Aug-2024 9/19/24

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

C1 Payroll

(©) For Services or Goods furnished / NOTARY FEE FOR CLAUDIA L SAMANO /

0 Treasurer‘s refund/payment
| Other: / check presumed lost / fund : 265 , initiated by the dept and vendor

@ ADRIAN
TES

SECRETARY OF STATE

September 13”, 2024

Maricopa County
Community Health & Records Services
Attn: Gabriela Rodriguez-Rhodes

Re: Affidavit/Claim for check #3010189366
Dear Ms. Rodriguez-Rhodes,
| Maria De La Hoya authorize Victoria Bustamante, Notary Supervisor, to execute an

affidavit on behalf of Arizona Secretary of State, Business Services Division.

Sincerely,

Mun4efebofe

/ Maria De La Hoya
Deputy Director — Business Services

“ .

Application Form Rejection Lefter
Adrian Fontes
Secretary of State
State of Arizona

Notary Application
Do not use White-Out.

Your request for Notary Applicaton {s rejected due to the following:

+ Application filing fee Is missing. Please resubmit with payment of $43 made payable to the SECRETARY OF STATE.
. » APPLICATION has been rejected, YOU MUST COMPLETE A NEW WEB APPLICATION with NEW BARCODE and

resubmit with Notarized bond. Make sure names/signatures match bond. ;

* Bond dates cannot overlap, your new commission cannot start until at least the day after yotlr previous commission
expires. .

+ Bond was/will be received in office 60 days after the effective date. Contact the bond company and request a
riderfnew fond with current dates. -

+ Other: APPLICATION BARCODE: 129788563

+ The printed name on the application does not match the printad name on the bond. PRINTED NAMES MUST
MATCH EXACTLY ON NOTARY APPLICATION AND BOND.

For questions, please contact the Business Services Division a
Revision Fall 2015 Ref #: 130241525 VB
9/4/2024 8:46:16 AM

ADRIAN Mail or Deliver To: Application ID Barcode

1700 W Washington St. 129788563
FONT ES a AINTINEL RIMINI
Secretary of State Phoenix, AZ 85007
State of Arizona Any questions: 602-542-6187 8/2/2024
‘ 326544 Renewal Notary Public Application

Applicant infdrmation

Name Claudia L Samana
Email Address claudia.samano@maricopa. Gender F D.O.B, 7/14/1978 = SSNH -HAH-HH-8161
gov

DL Type Valid license License or 1D # 814783958 Issued 11/2/2016 _ Expires 7/14/2043
Mailing Address 7104 W Fawn Dr Home Address 7104 W Fawn Dr Phone (602) 339-1021
Laveen, AZ 85339-3482 Laveen, AZ 85339-3482 County Of Residence

fe DQ Maricopa
Business/Employer Information
Business/Employer Name eine ie Haid record) Maricopa County
Business Address 3221 N 16th St Reo aE
Ste 100 ASE

Phoenix, AZ 85016-7158 roy ore
Business Phone (602) 506-6805 gt a res jane to Public? YES
oe :

ryt
Bond information paso!
Bond Issue Date 7/1/2024 Bond Effective Date 8/5/2024 — Bond End Date 8/4/2028
Bond Number 2309136-HNB Bond Company American Contractors Indemnity Company
Disclosure

Are you 18 years of age or older? “YES

Are you a citizen or a legal permanent resident of the United States of America? YES

Do you claim Arizona as your primary residence for state and federal tax purposes? YES
Can you read and write the English language? YES

Have you ever been convicted of a felony OR a lesser offense Involving moral
turpltude of a nature that Is Incompatible with the duties of a notary public? ~=NO

Have you ever had a professional license revoked, suspended, restricted, or denied for misconduct,
dishonesty, or any cause that substantially relates to the duties or responsibilities of a notary public? NO

Have you ever had a complaint opened against a previous notary commission? NO
Have you been commissioned as a notary public In any other state? NO
Applicant Attestation: Office of the Arizona Secretary of State

By signing below, { solemnly affirm, under penalty of perjury, that the answers to all questions on this notary
application and ali coples of documents Included with this application, are true, complete, unaltered and correct,
that | have carefully read and understand the notary faws (Title 41, Chapter 2, Article 2) of this state, and that if
appointed and commisstoned as a notary public, | will perform faithfully, to the best of my abllity, all notarial acts

(Mirra 2 Admawo Byoa/'a4

Sigrrature of Applicant (Required) Date

Notary Public Application # 129788563

J

F AMERICA

poND#2309136-HNB

” BOND OF NOTARY PUBLIC
ARIZONA

KNOW ALL B ¥ THESE PRESENTS:

That we, X _. Claudia Leticia Samano . 1 ; ; as Principal,
and TRAVELERS GASUALTY AND SURETY COMPANY OF AMERICA, a Connecticut corporation authorized to
transect surety business in the State of Arizona, as Surety, are helt and firmly bound unto the State of Arizona in the
penal sum of Five Thousand and No/100 ($5.000.00) DOLLARS, lawlul money of the United States of America, to be
paid to seid State of Arizona, or its assigns, for payment of which, well and truly be made, we bind ourselves, our
heirs, legal representatives, successors and assigns jointly and severally, firmly by those presents.

WHEREAS, the above bounden Principal was appointed by the Governor of Arizona to the office of Natary Public In and for

X_Maricopa County. Arizona, said appointment wil be effeclive__ 2 August
and ending __-1 August . 2028 _. (Dates must be filled in before the bond is filed)

NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH, That, if sald Principal shal! well, fruly and faithfully
perform ail official duties required of them by law, and shall well and falthfully execute and perform ail the duties of such
office of Notary Public required by any law to be enacted subsequent to the execution of this bond, then this obligation shalt
be void, otherwise to remain In full force and effect.

SIGNED AND SEALED THIS__1 day of __July , 2024 |

Q

WV Principal
TRAVELERS GASUALTY AND SURETY COMPANY OF. AMERICA

By ere. Petite] 0424903 7 By ‘pert Huctbtemez A124903

Arizona Residenl Agent Attornoy-n-Facl

OATH OF OFFICE

{Note 2 substitute for Oath required by Arkona

STATE OF ARIZONA
Communist Gontrat Act of 1981,28-231 Ariz Rev. Staf)

County of ¥_.Marigopa- -" ss
1. X_- Claudia Leticia Samano. “:. co solemnly swear {or affirm) that { will support the Constitution of the
United States and the Constitution and laws of the State of Arizona; that { will bear (rue faith and alleglance to the
same and defend them against all enemies whatsoever; and that I will faithfully and Impartially discharge the duties

of the office of Notary Public in according to the best of my abllily, so help me God, (or wi wii
id

XC Paudea.

. y 2
Subserlbed and sworn to before me in jhe Gounty of fee ‘Mar 1 LOA - State of Arizona this
LD: day of AUGUST

MANO

Principal

Notary Pubtte Stata of zona
Pinal Gounty

uez-Rhodes
Gabriels Rogrigt 0416/2025
‘Comeiasion Number 603321

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