REDACTED - FOR AGENDA ATTACHMENT - LINDA K. SMITH.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: 10.04.23

Subject: Affidavit ~ Linda K. Smith

Please find attached one Affidavit for two stale dated warrants 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.

» The original warrant is presumed lost.

Please call Marcia Bulanda at 506-7291 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: Stale Dated Warrants 3010128430 & 0023165532 - D180 ~ Finance — Fund 766 ~
PSPRS Tiers 1 & 2 Excess Contribution Refund 2022 — PSPRS1152

Application for a Duplicate or Stale-pared Warrant/Check

Affidavit/ Claim Forra

STATE OF ARIZONS
COUNTY GF MARIGOPA

fone Fast thdic fro:

LINDA K SMITH (1), being frst seer, upon oath denoses anc ays!
— & 28-Sep-2022
On oc about 23-Sep-2022 _. tate’. a warranticher ke wes issued te the

above camed personentity iy the amount as statad below, S
eile mever received ar was subsequenty inadvertentty. lest or
mo. ressodable probabiity of it Geing found or presented for payment, or it wae pot
Bresented for paynent within one year alter the date of issuance,

Therefore, under penalty of perjury, Caimant hereby. effirms that this clalo os correct
aad the amaunt shou is due afd owing, and the applicant requests that @ replacerne

warrant/cneck be issued to bim/hes In the sum of & 205.11 & $298.70 AM

Signed: <

Note- Please attach a cooy of the warrentycheck if avaiable andvor any over
evidence tat a warantohedkt was ongially issued.

“gaint gery

£5) Subscribed and sworn to before me ths G05 day et Beebe 2k |
NOTARY PUBLIC orn
RABY Fae,
Sarinngter Rinenty, Sa ateg z
My. commission express Myton Exes 137
a =f Zh (saath
Warrant check Number | AAT a niyeiess: ;
ie enone) (81 3010128430 & o0g3165532 _
| Original! Date of Issue an eit San?
if kroes C7 23-Sep-2022 28-Sep-2022 a

Redson far orginal sue of Warrant/Check (6):

{i} Payroll

CF Pof. Services or Goods furnished ener
Co. Treasurers refund/paymenit es

emai CAPE TE ER ataar Sees PR CPT PSPS THEA HS Sess ECR
iwed .
GP Other: se

couNTY Excense warrant TREASURER OF MARICOPA COUNTY

PHOENIX, ARIZONA

as

Two Hundred Five And 11/100 Dollars

PAY TO THE ORDER OF
LINDA K SMITH

For Questions - 602-506-1379 or email AP@MALL.MARICOPA.GOV
MARICOPA COUNTY DEPARTMENT OF FINANCE,

DATE
09-23-2022

Void After
365 Days

91-2/1221

WARRANT NUMBER
3010128430

$205.14

AMOUNT

NOT NEGOTIABLE

RETAIN THIS FOR | PAYEE, WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
PSPRS INT PAYMENT 3010128430 09/23/2022 $205.11
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
205.11

Portion Sept 2022

PSPRS1152 PSPRS Tiers 1 & 2 Excess Contribution Refund -1}GAX D180 2300000011774 |230000001171

co FILE # 000664-000657 ;
PCSPKA 000073641 Earnings Statement

. §122 811051891
Maricopa County

301 W. Jefferson St. . , Page 001 of 001
Suite 800 Period Ending: 09/18/2022
Phoenix, AZ 85003 Check Date: 09/28/2022
602-506-3519 Check Number: 0023165532
Batch Number: 220140001
Taxable Marital Status: $ x "
State AZ: 4.2%
Local: 0
. Hours / a ‘ .
Earnings " Rate Units . This Period Year-to-Date This Period Year-to-Date

Tax Withholding :
x -10.47

Vacation
Float Pers

— Notes

© 1998, 2006. ADP, INC_ All Rights Res

2017 ADP, LLC (POSUCH}

«@ TEAR HERE

LANCE $M SOME BEARD.

PONN EE ME SEY EEC)
(5 91-527/1221
Check

Check:Date: *... 09/28/2022

$**238.70

. This anioun

ASSISTANCE WITH VERIFICATION AVAILABLE AT 877-423-7243
Void Ny. 180 Po

_ Paytothe
*. order of”

ESP,

a ‘ADP AUTHORIZED SIGNATURE

HOLD WW REM GH

ATAN ANGLE TO VIE ENDONSEMEN Tid