STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - KATHERINE WUJCIKOWSKI.PDF
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v 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: 3/19/2024 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. e The original warrant is presumed lost and is stale dated. Please call Joyce Maurmann at 506-1343 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: Warrant #3010148470 / Katherine Wujcikowski Fund 219 — D190 GAXIF 230000020612 Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: [i] Duplicate or O Stale-Dated (definitions are on page 2) COUNTY OF MARICOPA numbers on the Instruction sheet which is page 2 of this form. Katherine Wujcikowski__(1), being first swom, upon oath depases and says: NameClaimant On or about 21-Apr-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 (3) (4) G) Subsorbed and som oboe meth é day of Janeany 20.244. MEE LEG NOTARY PUBLIC x Vf ber. ae (3010148470 Original ate Oe _|21-Apr-2023 Reason for original issue of Warrant/Check | (8): nt/check be issued to hi " CI Payroll (PA ay f° f 01 For Services or Goods furnished 1 Treasurer’s refund/payment / Other: Victim Compensation Check: 1978450-1 rqst 2 & 3 3/19/24 4 her in the sum of 934.90 0 COUNTY EXPENSE WARRANT Five Hundred Thirty Four And 80/160 Dollars PAY TO THE ORDER OF Katherine — For Qnosthons - 602-506-1379 or email AP@IMAIL, MARICOPA.GOY MARICOPA. COUNTY DEPARTMENT OF FINANCE. TREASURER OF MARICOPA COUNTY PHOENIX, ARIZONA Nis DATE WARRANT NUMBER 3010148470 / $534.90 AMOUNT Vold After 365 Days NOT NEGOTIABLE RETAIN THIS FOR YOURE RECORDS PAYEE WARRANTY NO. WARRANT DATE WARRANT AMOUNT VICTIM WITRESS 301614847 64/21/2023 $534.90 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCRER NO. AMOUNT O0000066659K 1978450-1-rqsi2 GAXIF D190 230000020612 495,00 23000002061 2 OO00DDE6658K 4978480-1-rqst3 GAXIF D196 230000020612 38.90 23000002061 2 CA CA