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MARICOPA COUNTY HARICOP, se Department of Finance 2021 APR . 12 PK 301 West Jefferson, Ste 960 1313 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: April 12, 2021 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit - Replacement of Lost Warrant Please find attached affidavit for lost warrant 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. e The original warrant has a void/stale date/stop payment done. Please call me at 506-1329 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Re: National Curriculum and Training Institute, Inc. (NCTI) Fund 219 Dept 190 Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or C1 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 paae 2 of this form. PSYCHOTHERAPY INNOVATIONS PLC (4) being first sworn, upon oath deposes and says: Name/Claimant On or about 20-Jan-2021 (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 $ 330.00 .(3) V, bool Loli Signed: (4) ae Note. ‘Please copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. 2 5 1 24 1 1 2 608 1745 85 38 92.501167 ibed 5 1 24 1 1 3 711 1754 219 29 76.871048 and|sworn 5 1 24 1 1 4 946 1747 42 35 96.696930 to 5 1 24 1 1 5 1006 1744 135 38 96.455467 before 5 1 24 1 1 6 1159 1754 64 28 96.379059 me 5 1 24 1 1 7 1238 1744 75 38 96.379059 this 5 1 24 1 1 8 1398 1717 79 64 49.168736 20 5 1 24 1 1 9 1539 1744 76 46 96.652252 day 5 1 24 1 1 10 1630 1743 44 38 96.652252 of 5 1 24 1 1 11 1731 1704 168 88 84.620125 Mowe 5 1 24 1 1 12 1912 1704 51 87 13.710976 Lh 5 1 24 1 1 13 2022 1744 50 37 67.125427 20 5 1 24 1 1 14 2116 1715 31 64 67.125427 A 5 1 24 1 1 15 2181 1773 8 8 81.236496 . 2 1 25 0 0 0 387 1921 353 38 -1 3 1 25 1 0 0 387 1921 353 38 -1 4 1 25 1 1 0 387 1921 353 38 -1 5 1 25 1 1 1 387 1922 180 37 96.531517 NOTARY 5 1 25 1 1 2 584 1921 156 37 95.888329 PUBLIC 2 1 26 0 0 0 700 1829 2 77 -1 3 1 26 1 0 0 700 1829 2 77 -1 4 1 26 1 1 0 700 1829 2 77 -1 5 1 26 1 1 1 700 1829 2 77 95.000000 2 1 27 0 0 0 383 1895 1559 16 -1 3 1 27 1 0 0 383 1895 1559 16 -1 4 1 27 1 1 0 383 1895 1559 16 -1 5 1 27 1 1 1 383 1895 1559 16 95.000000 2 1 28 0 0 0 1328 1907 629 137 -1 3 1 28 1 0 0 1328 1907 629 137 -1 4 1 28 1 1 0 1328 1907 629 50 -1 5 1 28 1 1 1 1328 1907 629 50 95.000000 4 1 28 1 2 0 1328 1957 281 44 -1 5 1 28 1 2 1 1328 1957 281 44 95.000000 4 1 28 1 3 0 1328 2001 204 43 -1 5 1 28 1 3 1 1328 2001 204 43 95.000000 2 1 29 0 0 0 1832 1957 125 44 -1 3 1 29 1 0 0 1832 1957 125 44 -1 4 1 29 1 1 0 1832 1957 125 44 -1 5 1 29 1 1 1 1832 1957 125 44 95.000000 2 1 30 0 0 0 1556 1968 330 136 -1 3 1 30 1 0 0 1556 1968 330 136 -1 4 1 30 1 1 0 1609 1968 223 22 -1 5 1 30 1 1 1 1609 1968 78 21 96.225403 BRYON 5 1 30 1 1 2 1696 1968 136 22 96.108093 WAGGONER 4 1 30 1 2 0 1603 2004 236 27 -1 5 1 30 1 2 1 1603 2005 65 26 91.654778 Notary 5 1 30 1 2 2 1676 2004 61 21 93.301491 Public 5 1 30 1 2 3 1746 2016 9 2 71.314667 - 5 1 30 1 2 4 1761 2004 78 22 95.170837 Arizona 4 1 30 1 3 0 1635 2041 172 27 -1 5 1 30 1 3 1 1635 2042 92 25 96.824570 Maricopa 5 1 30 1 3 2 1735 2041 72 27 96.786888 County 4 1 30 1 4 0 1556 2076 330 28 -1 5 1 30 1 4 1 1556 2078 28 26 96.951530 My 5 1 30 1 4 2 1592 2077 70 21 96.054474 Comm. 5 1 30 1 4 3 1672 2078 75 25 96.506065 Expires 5 1 30 1 4 4 1754 2078 35 20 96.743614 Jan 5 1 30 1 4 5 1797 2077 30 25 92.084862 28, 5 1 30 1 4 6 1834 2076 52 24 92.084862 2022 2 1 31 0 0 0 1328 2001 629 148 -1 3 1 31 1 0 0 1328 2001 629 148 -1 4 1 31 1 1 0 1328 2001 629 148 -1 5 1 31 1 1 1 1328 2044 228 105 95.000000 5 1 31 1 1 2 1925 2001 32 47 95.000000 2 1 32 0 0 0 387 2038 501 54 -1 3 1 32 1 0 0 387 2038 501 54 -1 4 1 32 1 1 0 387 2038 501 54 -1 5 1 32 1 1 1 387 2033 54 63 92.137642 My 5 1 32 1 1 2 422 2038 285 54 92.137642 commission 5 1 32 1 1 3 725 2038 163 40 87.261200 expires: 2 1 33 0 0 0 1886 2048 70 101 -1 3 1 33 1 0 0 1886 2048 70 101 -1 4 1 33 1 1 0 1886 2048 70 101 -1 5 1 33 1 1 1 1886 2048 70 101 95.000000 2 1 34 0 0 0 382 2133 610 9 -1 3 1 34 1 0 0 382 2133 610 9 -1 4 1 34 1 1 0 382 2133 610 9 -1 5 1 34 1 1 1 382 2133 610 9 95.000000 2 1 35 0 0 0 608 2187 384 16 -1 3 1 35 1 0 0 608 2187 384 16 -1 4 1 35 1 1 0 608 2187 384 16 -1 5 1 35 1 1 1 608 2187 384 16 95.000000 2 1 36 0 0 0 288 2298 1161 12 -1 3 1 36 1 0 0 288 2298 1161 12 -1 4 1 36 1 1 0 288 2298 1161 12 -1 5 1 36 1 1 1 288 2298 1161 12 95.000000 2 1 37 0 0 0 281 1698 20 713 -1 3 1 37 1 0 0 281 1698 20 713 -1 4 1 37 1 1 0 281 1698 20 713 -1 5 1 37 1 1 1 281 1698 20 713 95.000000 2 1 38 0 0 0 287 2101 7 310 -1 3 1 38 1 0 0 287 2101 7 310 -1 4 1 38 1 1 0 287 2101 7 310 -1 5 1 38 1 1 1 287 2101 7 310 95.000000 2 1 39 0 0 0 312 2090 1828 319 -1 3 1 39 1 0 0 312 2090 1828 319 -1 4 1 39 1 1 0 455 2090 1685 53 -1 5 1 39 1 1 1 455 2090 97 46 82.224037 Jan 5 1 39 1 1 2 1516 2127 388 17 26.196075 aaa 5 1 39 1 1 3 1936 2125 13 21 38.561172 | 5 1 39 1 1 4 2043 2099 97 40 96.851616 (seal) 4 1 39 1 2 0 312 2213 503 45 -1 5 1 39 1 2 1 312 2213 320 45 89.998306 Warrant/Check 5 1 39 1 2 2 647 2213 168 38 96.645912 Number 4 1 39 1 3 0 480 2231 784 73 -1 5 1 39 1 3 1 480 2269 35 35 96.747124 (if 5 1 39 1 3 2 526 2268 115 36 95.879791 known) 5 1 39 1 3 3 656 2269 45 35 96.786598 (6) 5 1 39 1 3 4 905 2231 359 49 88.865662 3010079871 4 1 39 1 4 0 312 2317 463 48 -1 5 1 39 1 4 1 312 2318 160 47 96.820885 Original 5 1 39 1 4 2 493 2319 95 36 96.028900 Date 5 1 39 1 4 3 606 2317 42 38 96.621033 of 5 1 39 1 4 4 663 2319 112 36 96.702911 Issue 4 1 39 1 5 0 480 2335 1657 74 -1 5 1 39 1 5 1 480 2373 34 36 96.453094 (if 5 1 39 1 5 2 525 2373 117 35 96.103546 known) 5 1 39 1 5 3 656 2373 45 35 96.517136 (7) 5 1 39 1 5 4 904 2335 366 50 93.808403 20-Jan-2021 5 1 39 1 5 5 1609 2394 8 9 0.000000 j 5 1 39 1 5 6 1863 2346 274 41 94.225723 04/12/2021 2 1 40 0 0 0 889 2188 4 222 -1 3 1 40 1 0 0 889 2188 4 222 -1 4 1 40 1 1 0 889 2188 4 222 -1 5 1 40 1 1 1 889 2188 4 222 95.000000 2 1 41 0 0 0 288 2403 1161 11 -1 3 1 41 1 0 0 288 2403 1161 11 -1 4 1 41 1 1 0 288 2403 1161 11 -1 5 1 41 1 1 1 288 2403 1161 11 95.000000 2 1 42 0 0 0 313 2478 1398 401 -1 3 1 42 1 0 0 313 2478 1398 401 -1 4 1 42 1 1 0 313 2478 1002 48 -1 5 1 42 1 1 1 313 2482 151 36 96.438690 Reason 5 1 42 1 1 2 482 2479 60 38 96.438690 for 5 1 42 1 1 3 557 2479 152 47 96.570724 original 5 1 42 1 1 4 728 2479 105 38 96.896927 issue 5 1 42 1 1 5 850 2478 42 38 93.290115 of 5 1 42 1 1 6 904 2478 320 46 92.030228 Warrant/Check 5 1 42 1 1 7 1241 2478 74 47 96.453850 (8): 4 1 42 1 2 0 387 2577 209 46 -1 5 1 42 1 2 1 387 2579 37 35 50.467815 C1 5 1 42 1 2 2 459 2577 137 46 96.359924 Payroll 4 1 42 1 3 0 458 2645 1253 58 -1 5 1 42 1 3 1 458 2666 67 37 96.962227 For 5 1 42 1 3 2 540 2666 172 37 95.716866 Services 5 1 42 1 3 3 729 2675 43 28 95.716866 or 5 1 42 1 3 4 788 2665 131 38 92.668556 Goods 5 1 42 1 3 5 934 2645 553 58 88.990364 furnished_Psycotherapy 5 1 42 1 3 6 1504 2645 207 40 96.907829 Services 4 1 42 1 4 0 386 2752 664 47 -1 5 1 42 1 4 1 386 2755 37 35 40.929050 C1 5 1 42 1 4 2 454 2753 238 39 89.861748 Treasurer’s 5 1 42 1 4 3 710 2752 340 47 91.082886 refund/payment 4 1 42 1 5 0 386 2840 202 39 -1 5 1 42 1 5 1 386 2842 36 36 29.415731 LC) 5 1 42 1 5 2 456 2840 132 39 95.968216 Other: 2 1 43 0 0 0 1132 2701 951 11 -1 3 1 43 1 0 0 1132 2701 951 11 -1 4 1 43 1 1 0 1132 2701 951 11 -1 5 1 43 1 1 1 1132 2701 951 11 95.000000 2 1 44 0 0 0 1063 2788 1030 11 -1 3 1 44 1 0 0 1063 2788 1030 11 -1 4 1 44 1 1 0 1063 2788 1030 11 -1 5 1 44 1 1 1 1063 2788 1030 11 95.000000 2 1 45 0 0 0 607 2875 1505 13 -1 3 1 45 1 0 0 607 2875 1505 13 -1 4 1 45 1 1 0 607 2875 1505 13 -1 5 1 45 1 1 1 607 2875 1505 13 95.000000 2 1 46 0 0 0 2240 1695 16 503 -1 3 1 46 1 0 0 2240 1695 16 503 -1 4 1 46 1 1 0 2240 1695 16 503 -1 5 1 46 1 1 1 2240 1695 16 503 95.000000 2 1 47 0 0 0 992 2193 1250 15 -1 3 1 47 1 0 0 992 2193 1250 15 -1 4 1 47 1 1 0 992 2193 1250 15 -1 5 1 47 1 1 1 992 2193 1250 15 95.000000 DocuSign Envelope ID: BC55FBFC-10BD-41B8-BBB1-13477294B516 Psychotherapy Innovations, PLC tA Phoenix AZ, 85014 , Office: Fax: March 20, 2021 Re: Affidavit/claim for re-issuance of a lost or stale-dated check (warrant) To whom it may concern: |, Julie Espinoza, authorize Tabatha Galarza, Office Manager, to execute an affidavit on behalf of Psychotherapy Innovations for the purpose of reissuing the lost check #3010079871 in the amount of $330.00. Sincerely, DocuSigned by: 93CF431B1C14461... Julie Espinoza, MA, LPC Co-owner Psychotherapy Innovations, PLC