STAMPED & REDACTED RBG COUNSELING AND CONSULTING.PDF

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

This application is for: Duplicate or C1 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.

RBG Counseling and Consulting-Joy Todd (4) hing first sworn, upon oath deposes and says:
Name/Claimant

On or about 17-Mar-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 ¢990.00 (3)
a on
va (4)

Signed:

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 Lf day of dctoba- 20 2.| .

AL bw" ck

NOTARY PUBLIC

ANA WCREY
NOTARY PUBLIC - ARIZONA
Maricopa County
| Commission # 556703

My Commission Expires
November 5, 2022

My me Sop. expires:

Warrant/check Number /QQ00060451K/ 00000301008461 5 |

Original Date of Issue
one it known) (7) 17-Mar-2021

Reason for original issue of Warrant/Check (8): 10/14/2021
O Payroll

C1 For Services or Goods furnished

(i Treasurer’s refund/payment

Other: Victim Compensation Check: 1842153-1 Req: 3

GOUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY

Krewe”

ofl TITRE“
veg!
a?
COUNTY
Nine Hundred Ninety And 00/100 Dollars

PAY TO THE ORDER OF
RBG Counseling and Consulting

PHOENIX, ARIZONA

DATE
03-17-2021

Void After
365 Days

WARRANT NUMBER
3010084615

91-2/1221

$990.00

AMOUNT

For Questions - or email NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN THIS FOR | PAYEE WARRANT NO, | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
RBG Counseling and Consulting 3010084615 03/17/2021 $990.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
GAXIF D190 210000012899 990.00

00000060451K 1842153-1-rqst3

210000012899

CA

Rise RBG Counseling and Consulting
Build
Grow

To Whom it May Concern:

Joy Todd, LPC is authorized to sign documents on the behalf of business entity RBG Counseling
and Consulting.

Thank you,

Joy Todd, LPC

Arizona Corporation Commission Corporations Division
Website Entity Detail.

Entity Details
ts . RBG COUNSELING AND ; .
Entity Name: CONSULTING LLC Entity ID: 23036295
Entity Type: Domestic LLC Entity Status: Active
Formation Date: 11/10/2019 Reason for Status: In Good Standing
Approval Date: 11/12/2019 Status Date:
Original Incorporation Date: 11/10/2019 Life Period: Perpetual
Business Type: a Seal Last Annual Report Filed:
ssistance
Domicile State: Arizona Annual Report Due Date:
Years Due:
Statutory Agent Information
Name: Joy Todd Appointed Status: Active 11/12/2019
Attention:
Address: Agent Last Updated: 11/12/2019
Attention: Mailing Address:
E-mail: County: Maricopa
Principal Information
‘, Date of Taking Last
Title Name Address Office Updated
Member and RBG Counseling and :
Manager Consulting Maricopa County, USA Lutonee LIAL 2h218
Entity Known Place of Business
Address: County: Maricopa Last Updated: 11/12/2019
Arizona Corporation Comunission Page 1 of 2

ANMIAIINAD 19.A6.19 DRA