STAMPED & REDACTED SUSIE RAMIREZ.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson

Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM =

a

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Date: August 30, 2021 =

2

To: Clerk of the Board =
From: Walter Chang wo “

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.

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: SUSIE RAMIREZ

+

C 4
OuN’S

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: Duplicate or CI 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.

SUSIE RAMIREZ (1), being first sworn, upon oath deposes and says:
On or about 21-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

vores fi to him/her i sum of $4,580.00 .(3)
Signed: (eee Ge 2 (4)
(SS ———

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 swotn to before me this EAM day of _( Auaust 20.2.

‘a \A—_
NOTARY PUBLIC CYS

My commission expires:
Vitis

Warrant/Check Number
check Nu 3010093525 9 ns
Original Date of Issue On
(if known) (7) 21-Jul-2021

Reason for original issue of Warrant/Check (8):

O Payroll
For Services or Goods furnished / SUSIE RAMIREZ RENTAL ASSISTANCE

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

08/31/2021