STAMPED & REDACTED - TIMOTHY P. BECKER.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 — TIMOTHY P BECKER

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.
© 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*0106
PSPRS Tiers 1 & 2 Excess Contribution Refund-Interest Portion Sept 2022
TIMOTHY P BECKER

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

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

STATE OF ARIZONA Note; Numbers on this form correspond to
COUNTY OF MARICOPA numbers on ane Instruction sheet which is
TIMOTHY P BECKER (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 him/her in the sum of $133.41 (3)

Signed: _[ eee ee (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’ | S _t > __ day of be Cem tober 2002..
Sena'fer Ann Movnel/

NOTARY PUBLIC YENNIFEN ANN MUNMELE
aN Notary eli « : Marleopa County
M comms expires: ae iy Commission Fane {
a A 4 as . December 24, 2023 >» ~— (seal)

Warrant/Check Number 3010128903

Cif known) (6)

Original Date of Issue
oN ie known) (D) 23-Sep-2022

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

Cl Payroll
(2 For Services or Goods furnished

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

FUND 766 - D180-FINANCE - GAX 23*0106
PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022,