TOUCHSTONE BEHAVIORAL HEALTH.PDF

MARICOPA COUNTY
Department of Finance 2613
301 West Jefferson, Ste 960 JIM I I AN 8: 4(..
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: June 11, 2019
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — TOUCHSTONE BEHAVIORAL HEALTH
Please find attached One Affidavit for stale dated warrant to be included on the next
available Board Agenda.
• The attached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.
• The original warrant is lost.
Please call me at 506-7291 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: FUND 227 — D270 — JUVENILE PROBATION

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
page 2 of this form.
TOUCHSTONE BEHAVIORAL HEALTH (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 27-Feb-2019 (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 hi er in the sum of $3,312.00 .(3)
Signed: (4)
Note: Please attach a cdpy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Notary MARISELA Public, State NOLAZCO of Arizona
My Commission MariooPa County Expires
October 14_2021
Warrant/Check Number 3010027432
(if known) (6)
Original Date of Issue 27-Feb-2019
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
El For Services or Goods furnished
LI Treasurer's refund/payment
Other: LOST WARRANT

ram touchstone
•
health services
partnering with families
Maricopa County Department of Finance
Attn: Accounts Payable
301 W Jefferson, Suite 960
Phoenix, AZ 85003
June 4, 2019
To Whom It May Concern:
I have full authority to sign on behalf of Touchstone Behavioral Health (dba Touchstone
Health Services).
Sincerely,
Lance R. Monahan,`CPA
Chief Financial Officer
ADDRESS 15810 N. 35TH AVE PHOENIX, AZ 85053 I WEBSITE TOUCHSTONEHS.ORG

'RsePro.6)-e\)
Q1
Bank Account: 1000 QI6rAK,0olt U9
Check/EFT Number: 000003010027432
Routing ID Number:
Transit Routing Number: fr)3.C.,
Check/EFT Amount: $3,312.00
Check/EFT Issue Date: 02127/2019
Print Status Indicator: I pi
Disbursement Category: Category:
Internal Reconciliation: N/A
Run ID: 338356
FM MCTO I Accounts payable 1, Common I Warrants I All warrants
Mr= _I Warrant I
/ Delete
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