REDACTED - FOR AGENDA ATTACHMENT - SURVIVORS TRUST - PAULA R. WESTERMEYER TRUSTEE.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

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

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

Cathy Sanchez oF

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

Re: Stale Dated Warrant

Name Warrant Amount | Dept/School
No
Survivors Trust 941354 $27.00 | Treasurer

Westermeyer Paula R Trustee

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: oO Duplicate or XM 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.

FRaeA K WEsTERMEVER, TRUSTE €%1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 4/ i. SOD (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 issuarice.

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 $. Pa, LO .(3)

Signed: (4)
Print name: (required) HubA RK. WESTARMEZER, Tens l EE

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 "1 day of Novem wr 2023.

LARISSA RAMIREZ CRUZ

. . i Notary Public - Arizona
My commission expires: PI Maricopa County

oO} 20] 7 O24 Commission #652109

my Comm. Expires Ju! 20, 2027 (Seal)
Warrant/Check Number
(if known) (6) 94 | 34Y

Origina! Date of Issue ,
° (if known) (7) 4/1 [20%

Reason for original issue of Warrant/Check (8):
0 Payroll

O For Services or Goods furnished

&. Treasurer’s refund/payment

O Other:

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc ay
Revised 100518 A.R.S. 11-632 & 11-644 i

RECEIVED tris

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NOV 2.0 2023 ye
MARICOPA COUNTY
TREASURER