STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JOHN P. DIBACCO PHD PC.PDF
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iy 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: 06.14.24 Subject: Affidavit — JOHN P DIBACCO PHD PC Please find attached one Affidavit for a duplicate lost/stolen 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 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: D560 PUBLIC DEFENSE —- FUND 100 — PRCPDIEDMMO006022 - OPDS CACE PAYMENT Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: = Duplicate or Cl 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. JOHN P DIBACCO PHD PC (1), being first sworn, upon oath deposes and says: Rame/Claimant On or about 22-04-2024 (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 payrnent 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 watrant/check be issued to him/her in the sum of $ 3325.00 -(3) signed: PALSY |) Kace— (4) Note: Please atiach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscrjbed and swom to befaye me this/777-_day oleae 2062. CMs YS 3 . rr sa DESIREE MW VERBOUS Notary Fublic - Arizone , Maricops County ne + Commission 4 607605 SSE my Corum. Eanires 7, 2625 NOFARY PUBLIC (W/commission expires; ye ad f__2 } (seal) Warrant/Check Numbe ¥ arranuiCheck Number 13010180241 _ Original Date of T: mene (if oon} o 22-04-2024 6/14/24 Reason for original issue of Warrant/Check (8): - 1 Payroll QO For Services or Goods furnished O Treasurer’s refund/payment C) Other; 2589 PUBLIC DEFENSE SERVICES - PRCPD1 24EDMM006022 - OPDS CACE Payment ~ 5:\PROCESSES\ Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc Revised Aprk 2015 ARS, 11-632 & 11-644 wary | GS | | | WARRANT NUMBER COUKY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY PHOENIX, ARIZONA 3010180241 DATE Three Thousand Three Hundred Twenty Five And 09/100 Dollars $3,325.00 PAY TO THE ORDER OF AMOUNT 365 Days For Questions - 602-506-1379 or email AP@MATL.MARICOPA,GOV NOT NEGOTIABLE MARICOPA COUNTY DEPARTMENT OF FINANCE RETAIN THIS FOR | PAYEE YOUR RECORDS. WARRANT NO. | WARRANT DATE WARRANT AMOU. 24EDMM006022 JOUN P DIBACCO PHD PC 3010180241 04/22/2024 $3,325.00 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT 20241364 CaselD: 87880 PRCPD1 D560 ~~ |24EDMMooso22| —«3,325.00 Warrant number — Issued date Paid date Amount s01ored2st + “01018024 ' ¥ ¥ + 3325.00] Warrant number 36 Amount Payee Account