STAMPED & REDACTED TOLLESON LHA II, LP.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: September 24, 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.
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 Office of Budget and Finance.

Thank you.

Re: Fund: 222 /Dept: Human Services / Company: TOLLESON LHA II

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

This application is for: Duplicate or CO Stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA deers Instruction sheet which is
TOLLESON LHA II, LP (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 03-Jun-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 oy in the sum of $ 3,300.00 .(3)

Signed: a (4)

Note. Aease asad 2 ay of the warrant/check if available and/or any other
ULAEC

evidence that @ warran k was originally issued.

(5) Subscribed and sworn to before me this gna day of Seplwbey 2021.

NOTARY PUBLIC MARIA D. VANEGAS
KP ER, Wotary Public, State of Arizons
My commission expires: 5 (WE)8) commission # §70094

ay zo/ 207.3 4 My Commission Expi(g&al

Qctaber 20, 2023

Warrant/Check Number
(if known) (6) 3010090038
Original Date of Issue
gine’ fknown) 7) 03-Jun-2021 09/27/2021

Reason for original issue of Warrant/Check (8):
CO) Payroll
For Services or Goods furnished _/ Tental assistance

O Treasurer's refund/payment
Other: / Original check presumed lost in the mail / fund : 222

( } : 101 North 91" Avenue | Tolleson, AZ 85353
i PHONE (623) 936-3740 | coppercove@dominiuminc.com
perre a& ' FAX (623) 936-8172 | copper-cove-apartments.com

August 25, 2021

|, Larry Holbrook, authorize Silda Teliez, Community Manager, to execute an affidavit on behalf of
Tolleson LHA Ii, LP.

Yours truly,
y fo a A

ie a
AN en ee

Larry Holbrook
Regional Manager