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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 828NOV 23 AMI): 36 Phoenix, Arizona 85003 ay INTEROFFICE MEMORANDUM Date: November 23, 2020 To: Clerk of the Board From: Walter Chang Department of Finance Subject: Affidavits - Replacement of Lost Warrants Please find attached 1 Affidavits for lost warrants to be included on the next available Board Agenda. e The attached items have been researched to ensure the warrant in question have not been cashed or previously re-issued. e The original warrants have a void/stale date/stop payment done. Please call me at 506 - 8747 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. Re: Fund:100 / Dept :100 - Superior Court / Company : AMIR DEZFULI Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or (| Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to COUNTY OF MARICOPA play neal sheet which is AMIR DEZFULI (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 27-Jul-2020 (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 $29.32 .(3) Signed: __ Aware AA : (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 ___— day of 20 NOTARY PUBLIE~ See ANLAa Ce) My commission expires: —\/ (seal) ———— nnn Warrant/Check Number = |3914QQ62468 (if known) (6) Original Date of Issue 97-Jul-2020 NOV 2 5 2020 | (if known) (7) Reason for original issue of Warrant/Check (8): LC) Payroll For Services or Goods furnished GRP Mileage Reimbursement C1 Treasurer's refund/payment Other: Presumed lost in the mail ; - Joam, fare ; This certificate is attached to a d page document deaing wph ented iy fay ydayis | AGM 0 dated \\ \ 2 | Wots California JURAT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Les Agyeles Subscribed and sworn to (or affirmed) before me on this ie) day of WOvemvoe 5 ,20%6 ,by AmiC Der Soir proved to me on the basis of satisfactory evidence to be the person(s/'who appeared before me. ‘ \. RHONDA M. GUTIERREZ COMM.# 2259618 NOTARY PUBLIC - CALIFORNIA g LOS ANGELES COUNTY My Comm, Expires Sept. 24, 2022 sonal (Seal) Printed 01-18 Produced by MarkMaster, Inc. | 1.800.441.MARK | www.markmasterinc.com