STAMPED & REDACTED - BLAS GABRIEL JR.PDF

MARICOPA COUNTY

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

INTEROFFICE MEMORANDUM

Date: January 5, 2023
To: Clerk of the Board
From: Yolanda Duran

Office of Budget and Finance

Subject: Affidavit— BLAS GABRIEL JR.

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*00439
PSPRS Tiers 1 & 2 Excess Contribution Refund-Interest Portion Sept 2022
BLAS GABRIEL JR

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

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

STATE OF ARIZONA Note: Numbers on this form correspond to

COUNTY OF MARICOPA humbers on the Instruction sheet which is
pade 2 of this form.

BLAS GABRIEL JR (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 $ 144.56 -(3)
Signed: LE cbt (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__*/ “day of we Muga, 20 23.
L Kl Age b.,

NOTARY PUBLIC’ ~ “SEM, DARYL A. DE ANGELO

CE@
(| ey) Notary ied - State of Arizona
a oo \(y MARICOPA COUNTY
My commission expires: 1) Commission # 563232
Percy 14, QOIR iaik> Expires May 14, 2023 (seal)

Warrant/Check Number 3010127742

(if. known) (6)
Original Date of Issue
- (if known) (7) 23-Sep-2022

1/09/2023
Reason for original issue of Warrant/Check (8): =

O Payroll
O For Services or Goods furnished

O Treasurer’s refund/payment
Other; _/ original check presumed lost in the mail

FUND 766 - D180-FINANCE - GAX 23*00439
PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022