REDACTED - FOR AGENDA ATTACHMENT - JOSE GEORGE.PDF
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MAR COPA COUNTY Office of Budget & Finance 301 W. Jefferson St., 9" Floor Phoenix, Arizona 85003 P: 602-506-3561 F: 602-506-4451 Maricopa.gov To: Clerk of the Board From: — Office of Budget & Finance, Accounts Payable Date: 12.20.23 Subject: Affidavit — Jose George Please find attached one Affidavit for one stale dated 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 presumed lost. Please call Marcia Bulanda at 506-7291 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: D180-OFFICE OF BUDGET AND FINANCE — FUND 766 - PRPRS TIERS 1 & 2 CONTRIBUTIONS REFUND 2022 — GAX 23*466 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 COUNTY OF MARICOPA Mes eon sheet which is JOSE GEORGE (4), 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 $ 136.44 - -() Signed: Aiea (4) q wi Note: plead attach a copy of the warrant/check if available and/or any other evidence that a warrant/check. was originally issued. (5) sti} aa ™Y to before me this _1 & day of DECEMB EE 29 2.3. ai Vo. G_ a a MELANIE GLOPEZ ‘NOTARY PUBLIC NOTARY PUBLIC - ARIZONA Maricopa es . Commission # My commission wpe Z My Commission Expires Kucus 4,2 nips 227 ea) Warrant/Check Number 3010128294 (if known) (6) Original Date of Issue 23-Sep-2022 Cif known) (7) Reason for original issue of Warrant/Check (8): OO Payroll C1 For Services or Goods furnished CO Treasurer's refund/payment Other: D180 - OFFICE OF BUDGET & FINANCE - FUND 766- PSPRS Tiers 1 & 2 Excess Contribution Refund 2022 COUNTY E/ PENSE WARRANT TREASURER OF MARICOPA COUNTY One Hundred Thirty Six And 44/400 Dollars PAY TO THE ORDER OF JOSE GEORGE For Questions - 602-506-1379 or email AP@MAIL MARICOPA. GOV MARICOPA COUNTY DEPARTMENT OF FINANCE PHOENIX, ARIZONA DATE WARRANT NUMBER 3010428294 P| —_ Void After 365 Days $136.44 AMOUNT NOT NEGOTIABLE RETAIN THIS FOR | PAYEE YOUR RECORDS WARRANT NO. | WARRANT DATE | WARRANT AMOUNT PSPRS INT PAYMENT 3010128294 09/23/2022 $136.44 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. VOUCHER NO. AMOUNT PSPRS441 PSPRS Tiers 1 & 2 Excess Contribution Refund - | Portion Sept 2022 GAX D180 230000000466 230000000466 136.44