STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JAQUON CLEMONS.PDF

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MARICOPA
COUNTY

Office of Budget & Finance To: Clerk of the Board
301 W. Jefferson St., 9 Floor

From: Office of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003

Date: 10/27/2023

Subject: Affidavit — Replacement of Lost Warrant |
P: 602-506-3561

F: 602-506-4451

Please find attached one Affidavit for a lost warrant to be included on the next
Maricopa.gov available Board Agenda.

« 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 Walter Chang at 506-8747 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 219 ~ D190 - County Attorney / Jaquon Clemons

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: Duplicate or CO state-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
paae 2 of ihis form.
Jaquon Ciemons (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 17-May-2023 (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 $645.00 (3)

(4)

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

Signed:

(5) Mid to before me this_1Lp day of Septemiber20Q4,

nook? ¥ PUBLIC Cie :

My gommission a
(JLAV) 2.

Warrant/check Number” 1499003010150754

Original Date of Issue
8 (if known) (7) 1 7-May-2023

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

C1 Payroll
( For Services or Goods furnished

[] Treasurer's refund/payment

other: Victim Compensation Check: 1788085-1, req #2

Una } OK IG

10/27/2023

COUNTY. EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER
PHOENIX, ARIZONA 3010150754

DATE
P| —

$645.00
PAY TO THE ORDER OF AMOUNT

365 Days

Six Hundred Forty Five And 00/100 Dollars

EGE Question’ ~-602-506- 1379" of email. AP@MAIL. MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN THIS FOR. | PAYER WARRANT NO.. | WARRANT-DATE | WARRANT AMOUNT
¥GUR RECORDS

VICTIM WITNESS 3010150754 08/47/2023 $645.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO, | VOUCHER'NO. AMOUNT
oangoosséesk 4788085-1-rgst2 GAXIF D190 230000022832 645.001CA

230000022832