REDACTED - FOR AGENDA ATTACHMENT - THE ROFFI FAMILY TRUST - RAYMOND P. ROFFI.PDF

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MARICOPA COUNTY

TREASURER’S OFFICE

John M. Allen, Treasurer
301 West Jefferson St., Rm. 100
Phoenix, Arizona 85003

Phone: (602) 506-8511

Fax: (602) 506-1102
http://treasurer.maricopa.gov

To: Clerk of the Board
clerk.agenda@maricopa.gov
Dorene.Stretar@Maricopa.Gov

From: Treasurer's Office ye
Maria Quitangon
maria.quitangon@maricopa.gov
602-506-1958

Cathy Sanchez Cs

cathy.sanchez@maricopa.gov
602-506-7881

Re: Stale Dated Warrant

Name Warrant Amount | Dept/School
No
The Roffi Family Trust 947112 $683.60 | Treasurer

NOV 20 2023

Application for a Duplicate or Stale-Dated arragity heck
Affidavit/Claim Form

This application is for: [1 Duplicate or B stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

RQ AYMoo? RbdZ if “L1), being first sworn, upon oath deposes and says:

Name/Claimant .
On or about £ I p) {[2> (date)(2) a warrant/check was issued to the
above named person/€ntity 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 $ a ¥ D G O .(3)
Signed: LZ WA 411 “HC. — (4)
Print name: (requifd) “R AY ALO KD (KAg- FL

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 day of Novande. 20 as.

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Se
NOREEN HOCKING.
ARY PUBLIC - ARIZONA
Maricopa County
Commission # 636990
‘iy Commission Expires
October 26, 2026

NOTARY PUBLIC

My commission expires: P

(seal)
Warrant/Check Number
(if known) (6) 9 of 7 f j aw
Original Date of Issue ay y)
(if known) (7) 0) [ 2~—
Reason for original issue of Warrant/Check (8):
0 Payroll
OO For Services or Goods furnished
BK Treasurer's refund/payment
O Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc ee?
Revised 100518 A.R.S. 11-632 & 11-644 \er
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