REDACTED - FOR AGENDA ATTACHMENT - BRAKES PLUS - BOB GIESE.PDF
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MAR COPA COUNTY Office of Budget & Finance 301 W. Jefferson St., 9% Floor Phoenix, Arizona 85003 P: 602-506-3561 F: 602-506-4451 Maricopa.gov To: Clerk of the Board From: Office of Budget & Finance, Accounts Payable Date: 5-14-2024 Subject: Affidavit — Replacement of Lost Warrant Please find attached one Affidavit for a lost warrant to be included on the next available Board Agenda. « The attached item has been researched to ensure the warrant in question has not been cashed or previously re-issued. « The original warrant is presumed lost. Please call Walter Chang at 506-8747 if you have any questions. Please return the approved Affidavit to my attention in the Office of Budget and Finance, 9" Floor. Thank you. Re: Fund : 232 / D640 - / Brakes Plus - Bob Giese Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or CO stale-Datea (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. Brakes Plus - Bob Giese (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 93-May-2023 (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 $ 2,900.00 G3) : C Signed? 7. , A a (4) PSs nent Sirk} EAL SS ~ Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. NWT (5) ry. sworn to me this haan 3H Mil Myril 202 Y. rea ane A ES ey 12 - s 7,1 NOTARY sat y ‘ Sr a z My. commission expires: £35, S : = Sith py = 2-20 De eat S OT | U if “ope. AL ABANE (seal) Warrant/Check Number (if known) (6) 3010149531 Original Date of Issue (if known) (7) 03-May-2023 Reason for original issue of Warrant/Check (8): O Payroll For Services or Goods furnished / BOND REFUND TC202201906 (1 Treasurer’s refund/payment Other: / check went stale / fund : 232 , initiated by the vendor R. Kent Feazell, EVP Real Estate Development & Franchise Support Direct Dial: |, R. Kent Feazell, authorize Summer M. Simpson, Director of Lease Administration, to execute an Affidavit on behalf of Brakes Plus, LLC Kindest regards, R. Kent Feazell EVP 4 PAY TO THE ORDER OF Two Thousand Five Hundred And 00/100 Dollars Brakes Plus - For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV MARICOPA COUNTY DEPARTMENT OF FINANCE Void After 365 Days $2,500.00 AMOUNT 149 NOT NEGOTIABLE WARRANT NO. | WARRANT DATE WARRANT AMOUNT RETAIN THIS FOR | PAYEE YOUR RECORDS MISCELLANEOUS BOND RETURN 3010149531 05/03/2023 $2,500.00 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT GAX1D D640 230000023054 2,500.00 R202222506 BOND REFUND TC202201906 230000023054