REDACTED - FOR AGENDA ATTACHMENT - ERICKA JORDAN.PDF

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: 11/21/2023

Subject: Affidavit — Ericka L. Jordan

Please find attached one Affidavit for a Stale-Dated 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 | 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*00651 ~ PSPRS Tiers 1 & 2 Excess Contribution
Refund — Interest Portion Sept 2022

Application for a ‘Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

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

STATE.OF ARIZONA Note: Nutabets:on this form correspond to
COUNTY: OF MARICOPA nambets on-the Instruction sheet which is
| page 2 of this form.
ERICKA L. JORDAN (1), béitig first'sworn, upon oath deposes and says:
Name/Ctaimant i .
On or about 23-Sep-2022 (aate)(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 of was subsequently inadvertently lost or destroyed and there is
noe réasonable probability of its being found or presented fer paymerit, 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 daim ts 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 $ 146.91 (3)
Signed: EGeh dan (4)

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

(6) a methis “7 _dayot_ L4gzAh 2024.

NOTARY PUBLIC’

Jacqueline Ortiz

. Notary Public
Maricopa County, Anzona

My Comm. Expires 07-07-23
Commission No. 568969

My commission expires:

mi (2 [223 (seal)

We t/Check Number
ae heck e- eT 13010128024

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

Reason for original issue of Warrant/Check (8):
O Payroll
C1 For Services or Goods furnished

C1 Treasurer's refund/payment
Other. / original check présumed lost in the mail

FUND 766 ~D180-FINANCE - GAX 23°00651.
PSPRS Tiers 1 & 2 Excess Contribution Refund - Interest Portion Sept 2022