STAMPED & REDACTED - MICHAEL PIERSEE.PDF

MARICOPA COUNTY

Office of Budget and Finance
301 West Jefferson, 9" Floor
Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: December 28, 2022
To: Clerk of the Board
From: Yolanda Duran

Office of Budget and Finance
Subject: Affidavit - MICHAEL L PIERSEE

Please find attached 1 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 lost.
Please call me at (602) 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-FINANCE- GAX 23*00991
PSPRS Tiers 1 & 2 Excess Contribution Refund-Interest Portion Sept 2022
MICHAEL L PIERSEE

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

This application is for: Duplicate or C1 state-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
Dade 2 of this form.
MICHAEL PIERSEE (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 Th issued to him/her in the sum of $ 132.86 -(3)
ae ZOOS (4)

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

Signed:

(5) Subscribed and sworn to before me this oe 7A day of Dex telhey 20-22.

NOTARY PUBLIC

STEPHENS!
EN Notary Public - Arizona |
F Maricopa Co. / #588371

My commission expires: Expires 08/17/2024
S17 [2024 (seal)

Ww t/Check Numb
oven (if lwo) “13010128542

Original Date of Issue
9 {if known) (7) 23-Sep-2022

Reason for original issue of Warrant/Check (8): / aoe 28/2022
1 Payroll
1 For Services or Goods furnished

O Treasurer's refund/payment
Other: / Original check presumed lost in the mail

FUND 766 - D180-FINANCE ~ GAX 23*00991
PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022