STAMPED & REDACTED - FOR AGENDA ATTACHMENT - DAVID CRISSINGER.PDF

Es

Ss

MAR COPA
COUNTY

Office of Budget & Finance
301 W. Jefferson St., 9% Floor
Phoenix, Arizona 85003

P: 602-506-3561
F: 602-506-4451

Maricopa.gov

To: Clerk of the Board

From: Office of Budget & Finance, Accounts Payable
Date: 07.24.24

Subject: Affidavit — DAVID E CRISSINGER

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

e Theattached 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 Marcia Bulanda at 506-7291 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 675 — D750 Risk Management — GAX1D 24*21424 — WC5005046167609

plication for a
ffidavit/ Claim

his application is fj

Orin

prs fad Duplicate

Duplicate or Stale-Dated Warrant/ Check

br (J stale-Dated thetintions are on page 4)

COUNTY OF MARI

oo OF ARIZON
AVID E CRISSING

a Nofe: Nun
LOPA instruction

bers on this form correspond to numbers on the
sheat which is page 2 of this form.

ER

{WamelClaimant

nm or about 17-06-

R024

bove named person,
ither never received
jo reasonable probab
yesented for paymen

erefore, under pen

entity in the amount
ior was subsequently
ility of its being foun
E within one year afte

hity of perjury, claim

{1), being first sworn, upon oath deposes and says.

(ehteX2) a warrant/check was issued to th
s stated below. Sich warrant/check wa

inadvertently jost or

id or presented for payment, gr it was ng
the date of issuance

ant hereby affirms thet this claim is corre

tS

destroyed and there

or AU

=

ind the amount shown is due and owing, afd the applicant requests that a replacement
arrant/check wr 3 to himsher in the shim of g 1454.67 | __(3)
$igned:__ td eine 4)
Note: Please attach 2 copy of the warrant/check if available and/or any other
evidence that 2 warrant/check was originally issued,
(5) Subscribed and sworn to before me this Altay of al ial 20 A
_ NOTARY PUBLIC
| M RARE LLE NN. DAVID
commission expires: . Notary Public Arzo
Vly ae ie 3 &| PINAL COUN a)
—— ZS ae ions vey | Commission # 660724
N. t/Check Numbér 14 -, aie ~
arran|
{if known) (6) —_ 301 018515} vo ae |
Driginal Date of Issue
Reason for original issue of Warrant/Check (8): 7/25/24
(J Payroll 7
1 For Services or Goods furished
Treasurer's refund/payment | ae |e
C Other: FUND 67§ - 0750 RISK MANAGEMENT - GAX1D 24*21424 | WC5005046167609

SF\PROCESSES\ Warrants - Duphal
Revised April 2015

pte or Stele\02 Forms\Warrants

thecks notice of clalm - Copy.cag

ARS. 11-632 R 11-444

counivexensewarrant TREASURER OF MARICOPA COUNTY

PHOENIX, ARIZONA

DATE
G1

One Thousand Four Hundred Fifty Four And 67/100 Dollars

PAY TO THE ORDER OF
DAVID E CRISSINGER

For Questions - 602-506-1379 or email AP@MAIL. MARICOPA .GOV
MARICOPA COUNTY DEPARTMENT OF FINANCE

Void After
365 Days

WARRAN
3010

91-2/1221

T NUMBER
185154

$1,454.67

AMOUNT

NOT NEGOTIABLE

RETAIN THIS FOR | PAYEE
YOUR RECORDS

WARRANT NO. WARRAN I DATE

WARRANT AMOUNT

T2ACRIS WC5005046167609 CRISSINGER

240000021424

__[sertrE 3010185151 06/17/2024 $1,454.67
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
(C5008 ° GAX1D D750 240000021424 1,454.67

Pu

Warrant number  fssued date

3010185131

Warrant curmbern 20404

Amount . Payee

545t

CRISSINGER,

Account

a

Paid date

v

Amount

y