REDACTED - FOR AGENDA ATTACHMENT - ROBERT PALMA.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: 01.25.24

Subject: Affidavit — Robert Palma

Please find attached one Affidavit for a Stale-Dated 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.

® 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, ot Floor.

Thank you.

Re: D180-Office of Budget & Finance-Fund 766-PSPRS Tiers 1 & 2 Excess Contribution
Refund 2022

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: O Duplicate or 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

page 2 of this form.
ROBERT PALMA (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 23-Sep-2022 (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 himber. in the sum of $ 162.39 -(3)
Signed: ‘ (4)

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

(5) Subscribed and sworn to before me this ia day of Jan ventyy 2X4.

. NOTARY PLC

Notary Public - State of Arizona
ee MARICOPA COUNTY
Commiagion € 657380
Expires May 14, 2025

aN JULIE A. COLE

My commission expires:
Mav. 4, 9da5

(seal)

Wi t/Check Number
even (if own) 6) 3010128730

Original Date of Issue 23-Sep-2022

(if known) (7)

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

O Payroll
0 For Services or Goods furnished

0 Treasurer's refund/payment
01480 - OFFICE OF BUDGET & FINANCE - FUND 766- PSPRS Tiers 4 & 2 Exes Contribution Refund 2022
Other: ers, acess Gontributlo

PHOENIX, ARIZONA

DATE

ENUMBE
3010428730

One Hundred Sixty Two And 39/100 Dollars
$162.39
PAY TO THE ORDER OF AMOUNT
Void After Bane ed 7
eo Mei 365 Days cb Z.
For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE .
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
| PSPRS INT PAYMENT 3010128730 09/23/2022 $162.39
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
GAX D180 230000000947 | 230000000947 162.39

PSPRS928

PSPRS Tiers 1 & 2 Excess Contribution Refund - |

Portion Sept 2022

8 All warrants Unsaved ff

C1. Agency Status Warrant number — Issued date Paid date Amount
. + 3010128730 + | + +
£2000 Stele 9/23/2022 12:00:08 am 9/25/20... 362.39
Warrant number SOM 28730
Amount | Payee Account
182.38 ROBERT PALMA