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MARICOPA COUNTY Office of Budget and Finance 301 West Jefferson Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: October 27, 2021 To: Clerk of the Board From: Walter Chang Office of Budget and Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached 1 Affidavits for lost warrants to be included on the next available Board Agenda. ® 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 Office of Budget and Finance. Thank you. Re: Fund: 222 /Dept: Human Services / Company : KALVIN CORCIO Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/ Claim Form This application is for: Duplicate or (I state-pated (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 farm. KALVIN CORCIO (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 16-Sep-2021 (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 $ 31,200.06 -(3) Signed: " # (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 ol day of OC 20.3) |. \ > 2 él MINERVA CANEZ z NO UBLIC eymeto\ Notary Public - Arizona fe) 5 MARICOPA COUNTY |. feel ; “ Commission # 589669 comthission expires: wr ei \ A rss aul otres Sep aes (seal) Warrant/Check Number ” Check Nu 3010098331 Original Date of Issue 4 (if knewn) (7) 1 6-Sep-202 1 Reason for original issue of Warrant/Check (8): 10/28/2021 1 Payroll 0 For Services or Goods furnished C1 Treasurer's refund/payment Other: / Original check presumed lost in the mail