STAMPED & REDACTED - FOR AGENDA ATTACHMENT - BRITNI MUELLER - 3010156032.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: 08.01.23

Subject: 2 Affidavits for Britni Mueller

Please find attached one Affidavit for a stale dated 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.

e 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: FUND 675 — D750 RISK MANAGEMENT — GAX1D 24*680 —
WC648821010632 MUELLER - Warrant # 3010156032

Application for = Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Duplicate or (] state-pated (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 this form.
BRITNI MUELLER (1), being first sworn, upon oath deposes and says:
NamnerClalmant
On or about 18-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, ar 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 die and owing, end the applicant requests that a replacement

warrant/check be issued to him/her in the sum of $3,353.57 3)

voy [ h, {
Signed: _Yyctinu Mw L ANT (4)

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

(5) Subscribed and sworn to before me this ae day of “ly 202 4

NOTARY PUBLIC

CARLOS STEWART LEE
Notary Public - Arizona
Pima County
Commission # 623474

My commission expires:

Marci | b i Beals dy Comm. Expires Mar 16, 2026 (seal)
Warrant/Check Number
(if known) (6) 3070156032
Original Date of Issue nite
Date of Is 48-Jul-2023 oe

Reason for original issue of Warrant/Check (8):
1 Payroll
For Services or Goods furnished_/ Workman comp

( Treasurer's refund/payment
Other: / check presumed lost / fund : 675 / intiated by Risk Dept

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER
Par PHOENIX, ARIZONA, 3010156032

DATE

07-18-2023 91-2/1224

Three Thousand Three Hundred Fifty Three And 57/100 Dollars

$3,353.57
AMOUNT

PAY TO THE ORDER OF
BRITNI MUELLER

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
TOUR RECORDS

SETTLE 3010156032 07/18/2023 $3,353.57
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
823MUEL WC648821010632 MUELLER GAX1D D750 240000000680 3,353.57/PU

240000000680