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MARICOPA COUNTY BOARD OF Department of Finance 301 West Jefferson, Ste 960 2628 SEP 25 PM 12: 37 Phoenix, Arizona 85003 en Devic 4 Me INTEROFFICE MEMORANDUM Date: September 25, 2020 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit — Notice of Claim Please find attached Affidavit for stale dated warrant to be included on the next available Board Agenda. e The attached item has been researched to ensure that warrant in question has not been cashed or previously re-issued. e The original warrant has a void/stale date/stop payment done. Please call me at 506-1329 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Re: GMPH ONE INCD KAIZEN COLLISION CENTER Dept. 750 Fund 675 KAIZEN OOLUT SON CENTER September 23, 2020 Maricopa County Department of Finance Attn: Beth Brown 301 W Jefferson, Suite 960 Phoenix, AZ 85003 RE: Affidavit for Re-issuance of Lost Check Dear Ms. Brown |, Jacob L. Tilzer, authorize Melissa G. Cole, Chief Financial Officer, to execute an affidavit on behalf of Kaizen Collision Centers. Sincerely, 4674 Jacob L. Tilzer President 1920 W Deer Valley Road, Phoenix AZ 85027 250 N Pasadena Street, Gilbert AZ 85233 8175 E Raintree Drive #6, Scottsdale AZ 85260 622 S Hacienda Drive, Tempe AZ 85281 3325 S Bonanza Road, Yuma AZ 85365 2111 Morena Boulevard, San Diego CA 92110 3580 Olive Street, Lemon Grove, CA 91945 ICO ih Shia | ee OuUNsS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or CI 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. GMPH ONE ING KAIZEN COLLISOIN CENTER (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 05-May-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 $ 14,315.94 (3) signed We leade 1. a _. (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 23 day of Secsterrks-20,20, “Donen Ralasr NOTARY PUBLIC GEER . DAWN ROBERTSEN 2a) lotary Public - Arizona My commission expires: (eS) Maricopa County \A- 3D ©) My Co Eee sap 17, 2023 (seal) Warrant/Check Number aif known) (6) 3010058226 Original Date of Issue ane) 05-May-2020 Reason for original issue of Warrant/Check (8): - P 30 2020 O1 Payroll For Services or Goods furnished Auto Repair (1 Treasurer's refund/payment Other: