STAMPED & REDACTED - FOR AGENDA ATTACHMENT - ERIC ANDERSON.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: 9-21-2023

Subject: Affidavit — Replacement of Lost Warrant

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

@ The attached item has been researched to ensure the warrant in question has not
been cashed or previously re-issued.

® The original warrant is presumed fost.

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 / Eric Anderson

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: Duplicate or (] stale-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
. page 2 of this form.
Eric Anderson (1), being first sworn, upon oath deposes and says:
On or about 29-Jul-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, er 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 $01 5.30 (3)
Signed: Le Lite. ft hr (4

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 Ut day of Sftemher 2923,

NOTARY PUBLIC

NICOLAS DAVIS
Notary Public - Arizona
Pinal County
Commission #594256

My Gomm, Expires 1/22/2025

My commission expires:
Gl-2L%e- 25

Warrant/Check Numbe is
rrant/Check Number 13040456511
Original Date of I
One non) (20-Jul-2023

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

(seal)

10/11/2023
C1 Payroll ,

O For Services or Goods furnished

O1 Treasurer's refund/payment

Other: Victim Compensation Check: 1964524-1 Request 3

county exrensewarrant TREASURER OF MARICOPA COUNTY — WARRANT NUMBER
PHOENIX, ARIZONA 3010156511
DATE
Or 208 91-2/1224
Five Hundred Fifteen And 30/100 Doliars
$515.30
PAY TO THE ORDER OF AMOUNT
Void After
365 Days
For Questions - 602-506-1379 or email AP@MAIL. MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
VICTIM WITNESS 3010186511 07/25/2023 $515.30
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
00000067280K 1964524-1-rqst3 GAXIF D190 240000001359 515.30/CA

240000001359