REDACTED - FOR AGENDA ATTACHMENT - QUIKTRIP CORPORATION 952436.PDF

John M. Allen, Treasurer
301 West Jefferson St., Rm. 100
Phoenix, Arizona 85003

lL
MA R) COPA COUNTY re lon eee tae

TREASURER’S OFFICE

http:/ /treasurer.maricopa.gov

To: Clerk of the Board
clerk.agenda@maricopa.gov
Dorene.Stretar@Maricopa.Gov

From: Treasurer’s Office v/

Maria Quitangon
maria.quitangon@maricopa.gov
602-506-1958

Cathy Sanchez al)

cathy.sanchez@maricopa.gov
602-506-7881

Re: Stale Dated Warrant

Name Warrant Amount Dept/School
No
Quiktrip Corporation 952436 $12,754.35 | Treasurer

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 numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

QUIKTRIP CORPORATION _(1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/17/2022 (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.

* To the best of our knowledge, the check/warrant was not received and became lost in the mail.
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 $. $12,754.35 -(3)

Signed: (4)

Print name: (required) _G. Harold Christian, VP Operations (Atty-in-Fact)

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 anid sworn to before me this_| ("day of \\Awoaey 2024 .
(4 \) WR JEWEy! “Ny

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NOTARY-PUBLIC ORBAN WEN SES Se, a,
: 7! REGISTRATION No

7990776 :
My commission expires: iMy COMM. EXPIRES!

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Original Date of Issue

(if known) (7) 11/17/2022

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

O For Services or Goods furnished

Treasurer's refund/payment

QO Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc
Revised 100518 A.R.S. 11-632 & 11-644 yi 169

ven o)e4
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189767

Maricopa County Treasurer's Office

Refund ID 2022023413 MTG_BATCH

&, Refund ID 2022023413 MTG_BATCH
File Help

EQIey

$12,754.35

Refund Amount:

Requester, [MORTGAGE on 11/2/2022

| Refund Reason: [Mortgage Rejects - see attached list

Status: [DISBURSED on 1142/2022

Slip ID; {202200836

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Address: QUIKTRIP CORPORATION

Impounds | Stub | Comments |

Check Request. |MORTGAGE DESK

Reference #: [MTGBATCH 00571

Z

Impound #1

Amount | Tax Year | State

Source Fund | Linked |
064 False $12,754.35 2022
<

REA

Parcel/Roll:|000-00-000 Dest fund: [026
CPH: Jo Reso#: (0
CP buyer # Jo Phase #: |0

Mortgage code: [4172

Impound Total : 1

Transaction #: [mo Al?2
Case #: J

12/6/2023 2:05:41 PM