STAMPED & REDACTED - FOR AGENDA ATTACHMENT - ERIKA JORDAN.PDF

MARICOPA
COUNTY

Office of Budget & Finance
301 W. Jefferson St., 9" Floor
Phoenlx, 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: 02.22.24
Subject: Affidavit — Ericka L. Jordan

Please find attached one Affidavit for a duplicate 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 Marcia Bulanda at 506-7291 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 766 — D180 OBF ~ GAX 24*012 — PSPRS Tiers 1 & 2 Excess Contribution Refund
2022

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: Duplicate or (J state-Dated (definitions are on page 2)

STATE OF ARIZONA
COUNTY OF MARICOPA

ERICKA L. JORDAN

Name/Claimant

On or about 12-Dec-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.

numbers on the Instruction sheet which is
pade 2 of this form,

(1), being first sworn, upon oath deposes and says:

Note: Numbers on this form correspond to |

‘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 $146.94 (3)

(4)

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

Signed: °° Ge?

tt

(5) Subscribed and sworn to before me this “2% day of Féivismvir 2024).
}
ft Giper v

NOTARY PUBLIC . Ana Simentai

Notary Public
} Maricopa County, Arizona
¥ My Comm. Expires 10-03-26

My commission popes:

6/3} ae Commission No, 641140 (seal)
Warrant/Check Number
‘if known) (6) 3010168286
Original Date of Issue
|G knawn) (7) 12-Dec-2023

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

Payroll
C1 For Services or Goods furnished

(1 Treasurer's refund/payment
* 2
f@ Other: Fund 786 » oerwanee: GAX 24*012 - PSPRS Tiers 1 & 2 Excess Contribution Refund 2022

VA

2/22/2024

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY

c % PHOENIX, ARIZONA

DATE
12-12-2023

One Hundred Forty Six And 91/100 Dollars

PAY TO THE ORDER OF
ERICKA L JORDAN

Vold Alter
365 Days

WARRANT NUMBER

3010168286

91-2/1221

$146.91
AMOUNT

For Questions - 602-506-1979 or email AP@MALL.MARICOPA. GOV” NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN SHES FOR | PAYEN. WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS *

PSPRS INT PAYMENT 3010168286 12/12/2023 S146,9'1
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO, | VOUCHER NO, AMOUNT
PSPRS628 REISSUE PER AFFIDAVIT 3010128024 GAX D180 240000000012 |240000000012 146.91; PU