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MARICOPA COUNTY Department of Finance Y It\P-t‘ 301 West Jefferson, Ste 960 2013 MAY 13 AtIll: 414 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: May 13, 2019 To: Clerk of the Board From: Walter Chang Department of Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached 1 Affidavits for lost warrants 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 warrants have a void/stale date/stop payment done. Please call me at 506-8747 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. Re: Fund : 100 / Dept : Treasurer /D430 / Company: Goldfield Medical Clinics LLC Trust Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 Duplicate or s' 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. Goldfield Medical Clinics LLC Trust (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 13-Apr-2018 (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 $ 5,24097 .(3) Signed: (4) Note: Please '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 before me this v1 day of IPI)Q,1 20 1 . NOTARY PUBLIC Heather Wood My commission expires: Notary Public \ - Maricopa County, Arizona (seal) My Comm. Exp. 01-04-2021 Warrant/Check Number 872150 (if known) (6) Original Date of Issue 13-Apr-2018 (if known) (7) Reason for original issue of Warrant/Check (8): O Payroll O For Services or Goods furnished O Treasurer's refund/payment Other: presumed lost in the mail Dr. Shantha Kumar, M.D. FACC Goldfield Medical Clinics, LLC 99 S. Gold Drive, Suite 5, Apache Junction, AZ 85120 Phone: (480) 962-0101 Fax: (480) 962-0202 February 8, 2019 I, Shantha Kumar authorize Mary Coker to execute an affidavit for Goldfield Medical Clinics, LLC. Yours Truly, Manager of Mary Coker