STAMPED & REDACTED MIKE CARRILLO.PDF

MARICOPA COUNTY
Department of Finance

301 West Jefferson, Ste 960
Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: September 9, 2021 ~
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To: Clerk of the Board i
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From: Beth Brown =
Department of Finance wo

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Subject: Affidavit - Replacement of Lost Warrant : 2

Please find attached affidavit for lost warrant to be included on the next available Board

Agenda.

e The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.

e The original warrant has a void/stale date/stop payment done.

Please call me at 506-1329 if you have any questions. Please return the approved

Affidavit to my attention in the Department of Finance, Suite 960.

Thank you.

Re: MIKE CARRILLO
DEPT 190

FUND 219

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

This application is for: Duplicate or oO 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.
Mike Carrillo (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 28-Jul-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 $97.20 .(3)
Signed: Nf ——— 4
9g b (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 _ 2 ‘2 day of GEPLERBER 202 .

NOTARY PUBLIC

ENRIQUE CRUZ PENA
Notary Public - State of Arizona
MARICOPA COUNTY

My commission expires: Commission #607065

IVS 3. Seo Expires July 3, 2025 (seal)
Warrant/Check Number
iCheck Number 13040094265
Original Date of Issue
Reason for original issue of Warrant/Check (8): : -
1 Payroll

OO For Services or Goods furnished

1 Treasurer's refund/payment
Other: Victim Compensation Check

GAX Interface(GAXIF) Page 1 of 1

GAX Interface(GAXIF) Dept: D190 ID: 220000001613 Ver.: 1 Function: New Phase: Final
Modified by batchadm , 07/28/2021

Header fel

General Information Payee Additional Amounts Extended Description Contact Document Information

Document Name: Pre-Processing Allowed:
MVICTIM INTERFACE

Bank Account:
Record Date:

07/28/2021 Replacement:

Budget FY: oO

2022 Contract Withholding Exempt:
Fiscal Year:

2022 Cited Authority:

Period:

1 Escrow ID:

Document Description:

MVICTIM INTERFACE a Vendor Invoice Number:
Accounting Profile: Vendor Invoice Line:
Expected Amount: Vendor Invoice Date:

$0.00

Actual Amount: Tracking Date:

$97.20

Closed Amount: Check Description:

$97.20 as
Closed Date: oa
07/28/2021

Open Amount:

$0.00

Referenced Amount:

$97.20

https://azdom.hostams.com/PRDFIN2X 1/advantage/Advantage/document_to_print.html 9/9/2021

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER

PHOENIX, ARIZONA 3010094265
DATE
07-28-2021 91-2/1221
Ninety Seven And 20/100 Dollars

PAY TO THE ORDER OF eerze

Michael Carrillo | eee
Void After
365 Days

For Questions ~ NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE

RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT

YOUR RECORDS
VICTIM WITNESS 3010094265 07/28/2021 $97.20
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
00000061827K VC2018000252-1-rqst11 GAXIF D190 220000001613 97.20;CA

220000001613