INNERSPECTIVE PSYCHOLOGICAL SERVICES.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960 2019 JUN 28 PH 12:
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: June 28, 2019
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.
• The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.
• 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: lnnerspective Psychological Services
oeo z o FiFi d )(Do

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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
Dane 2 of this form.
INNERSPECTIVE PSYCHOLOGICAL SERVICES LLC (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 01 -Mar-2019 (ciate)(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/checq,e is, d - to hirpher in the sum of $ 1,640.00 .(3)
'Ai'
Signed: Le.... A11.07 (--- ZS (4)
/ w
Note: Please att ch a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued
(5) Subscribed -40.404.• - e this 4577/ day of /)x, 20 /f .
;LI 411Pr."
JOSEPH R comma
My commission expires: STATE NOTARY OF COLORADO PUBLIC
WCOMMISSION NOTARY ID EXPIRES 20164021390 JUNE SION
Co./Cc, /2 csA0 (seal)
Warrant/Check Number 3010027776
(if known) (6)
Original Date of Issue 01-Mar-2019
(if knownE7)
Reason for original issue of Warrant/Check (8):
0 Payroll
Li For Services or Goods furnished
El Treasurer's refund/payment
CI Other: Adult- IN-CUSTODY - Rule 11 Competency Evaluations/Fees

Katherine Spector Psy.D. 623-213-4452
Licensed Psychologist, AZ & CO lnnerspectivePsychgmaiLcom
June 21, 2019
To Whom It May Concern.
This letter is to attest that Katherine Spector, Psy.D. is the owner and sole proprietor of
:lnnerspective Psychological Services, LLC. She has full signing privileges in all matter related
to Innerspective Psychological Services, LLC's business contracts and financial matters.
Feel free to contact Dr. Spector using the information below with any further questions you may
have.
Kind Regards,
Katherin-e Spector, Psy.D.
Licensed Psychologist
Owner / Psychologist
1nnerspective Psychological Services, LLC,
syq gp
623-213-4452