STAMPED & REDACTED - FOR AGENDA ATTACHMENT - CHARLES GREEN.PDF

MARICOPA
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: 2-29-2024

Subject: Affidavit — Replacement of Lost Warrant

Please find attached one Affidavit for a lost warrant to be included on the next
available Board Agenda.

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 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 219 — D190 County Attorney / Charles Green

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

This application is for: [] Duplicate or L 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.
Charles J Green (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 18-Aug-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

vere? Ur eT me of $2,600.00 (3)
Signed: (4)

Note: Please attach a diy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

(5) ae and sworn to before me this __ x 0 day of Lrbhu GA ve 20 2-1
wwe
‘0 hn EZ aVOu? as w"E. on
NOTARY PUBLIC §9: So ee Be
wore ‘xe
My commission expires: Bei y x eiv8
“AS - 202) % “gg or eas
* IES 08-0" Sy
a My # Osis
Warrant/Check Number 000003010158605 Man OOK
Original Date of Issue |
(if known) (7) 1 8-Aug-2023
Reason for original issue of Warrant/Check (8): y 3/7/24
1 Payroll 7

UI For Services or Goods furnished

1 Treasurer’s refund/payment
= Other: Victim Compensation Check: 1929359-1 req #8

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY

PHOENIX, ARIZONA

DATE
08-18-2023
Two Thousand Six Hundred And 00/100 Dollars
PAY TO THE ORDER OF
Charles Green
Void After
385 Days

WARRANT NUMBER
3010158605

97-2221

$2,600.00
AMOUNT

For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV
MARICOPA COUNTY DEPARTMENT OF FINANCE

NOT NEGOTIABLE

RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
VICTIM WITNESS 3010158605 08/48/2023 $2,600.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
00000067421K 1929359-1-rqst8 GAXIF D190 240000003543 2,600.00] CA
240000003543