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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM = 5 <= Date: August 20, 2020 ne ; fo ] To: Clerk of the Board — ae = Fis — > \ From: Walter Chang oe A Department of Finance 4 % i Subject: Affidavits — Replacement of Lost Warrants 4 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:222 / Dept: 220 - Human Services / Company : WEST USA REALTY INC Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: M4 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 ; page 2 of this form. WEST USA REALTY INC (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 24-Jun-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 oS. the sum of $424.00 (3) Signed: is _ = ad (4) Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. - YAN ZIMMERMAN \ Notary Pu! Sate ol ee md i ARIGOPA CO 0 12D). st ty Gomsson Expres af22f2* roto 201 | cea Warrant/Check Number 3949960981 (if known) (6) Original Date of Issue (if known) (7) 24-Jun-2020 Reason for original issue of Warrant/Check (8): O Payroll For Services or Goods furnished RENTAL ASSISTANCE PMT / COVID related 1 Treasurer's refund/payment 1 Other: Residential « Land * Commercial + Investments ms |; 16150 N, Arrowhead Fountain Center Dr. Suite 100 * Peoria, AZ 85382 + (623) 487-5096 DATE: 08/19/2020 |, Duane Fouts, authorize Angelo R Rivers, administrator, to execute an affidavit on behalf of WEST USA REALTY. Yours truly, 8/19/2020 | 3:17 PM MST Duane P Fouts Duane Fouts Designated broker