STAMPED & REDACTED - FOR AGENDA ATTACHMENT - BRITNI MUELLER 3010153674.PDF

MAR ' COPA :
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: 08.01.23

Subject: 2 Affidavits for Britni Mueller
P: 602-506-3561

F: 602-506-4451

Please find attached one Affidavit for a stale dated 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 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 23*25958 — WC648821010632
MUELLER ~ Warrant #3010153674

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: [y] Duplicate or Cc] 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
nage 2 of this form.
BRITNI MUELLER

(1), being first sworn, upon oath deposes and says:

‘Name/Claimant

On or about 20-Jun-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

anc the arount shown is due eric owing, and the applicant requests that a replacement

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

Signed: Prout Mua | i a (4)

Note: Pease 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 befare me this Xs day of Y 2024,
NOTARY PUBLIC
CARLOS STEWART LEE
aoe » Notary Public - Arizona
My commission expires: Pima County
/Maiee bo He; pods iy comm Bae har 14. 2026 (seal)
Warrant/Check Number x
(it known) (6) 3010153674
Original Date of Issue oa
eos 20-Jun-2023 3/2/2003
Reason for original issue of Warrant/Check (8): .

C Payroll
(4 For Services or Goods furnished_/ Workman comp

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

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER

<it, PHOENIX, ARIZONA 3010153674
See we DATE
() ce (i 06-20-2023 o1-211224

oO oo

oont
Three Thousand Three Hundred Fifty Three And 57/190 Dollars I

$3,353.57
AMOUNT

PAY TO THE ORDER OF
BRITNI MUELLER

Void After
365 Days

For Questions - 602-506-1379 or emai] AP@MALL.MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE,
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOURREECORDS

SETTLE 3010153674 06/20/2023 $3,353.57
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
723MVEL WC648821010632 MUELLER GAX1D D750 230000025958 3,353.57}PU

230000025958