STAMPED & REDACTED- EDIBERTO V. LARA.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 - EDIBERTO V LARA

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*0712
PSPRS Tiers 1 & 2 Excess Contribution Refund-Interest Portion Sept 2022
EDIBERTO V LARA

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: 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
pade 2 of this form.
EDIBERTO V LARA (1), being first sworn, upon oath deposes and says:
Name/Cialmant
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 him/her in the sum of $ 144.86 -(3)

Signed: Zz —_ (4)

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 and sworn to before me this-13 77 _day of _Pecemper~ - 20:22..

Chittann. Tt wile

NOTARY PUBLIC

My commission expires:

FEB ?m  Qeas (seal)
Warrant/Check Number
Check Nu 3010127994
Original Date of Issue
one if known) () 23-Sep-2022 12/28/2022

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

1 For Services or Goods furnished

1 Treasurer's refund/payment
Other: / original check presumed lost in the mail

FUND 766 - D180-FINANCE - GAX 23*0712
PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022