STAMPED & REDACTED - FOR AGENDA ATTACHMENT - 728 N LAGUNA DR LLC.PDF

v
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: 6-27-2024

Subject: Affidavit — Replacement of Lost Warrant

Please find attached one Affidavit for a lost warrant to be included on the next
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 : 296 and 222 / D220 - Human Services / 728 N LAGUNA DR LLC

Date 6/27/2024

To whom it may concern

728 N LAGUNA DR is single property and the property is set up under an He- 728 N LAGUNA DR
LLC. This Ile is a sole proprietor Ile and Andrew Searl is the only owner with no employees.

I, Andrew Searlam the only party authorized to sign the affidavit on behalf of 728 N Laguna Dr LLC

Andrew Searl

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

This application is for: Duplicate or C) 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.
728 N LAGUNA DR LLC (1), being first sworn, upon oath deposes and says:
Name Claimant

On or about 25-Apr-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

(3)

(4)

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 Z1 day of June 2024.

| att, Hert

NOTARY PUBLIC —
My qan'ssgn expires:
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[paren ere = lSsoiOS0sd2

fas nce IRR) (6) | ee HOEK =

| Original Date of Issue
Me niece 25-Apr-2024 ’ 6/28/24

ELIZABETH K. HUGGETT
Notary Public - State of Arizona

7 Commission #603479

Expires: May 23, 2025 (seal)

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

1 Payroll
© For Services or Goods furnished / SMITH, JAELEEN - RENTAL ASSISTANCE

() Treasurer’s refund/payment
[ Other: / check presumed lost / fund ; 296 and 222 , initiated by the vendor