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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: April 10, 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: ARIZONA DEPARTMENT OF HEALTH SERVICES Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/ Claim Form This application is for: El DU plicate or 0 Stale-Dated, (definitions are on page 2) PT.:WPFARjzONA Note: Numbers on tnislonnooriesponflo COUNTY OF MARICOPA northers on:ItieinstrtiotiorrAe4Whioh is of this.form, ARIZONA DEPARTMENT OF HEALTH SERVICES (1), being first SWoftf..i1POn - . . . Oath . deposes .-. says' • - Name/coma , .0n, or :abOut Kilht6X2) a wpffarit/Oecic was issued to the .personientityAh.the:amountasstated:belam Such.:warranticheck was .:.dithef:neVer..received or was subsequently inadvertently lost or destroyed and there is no :reasonable probability of jt.S.:: lj*g foUnd..or presented, for payment, .Or it was not -,pre.serited. for paymentwithirt one.yearafter -the. ..ate cf .issuance. .therefore, :under penalty of -perjury; claimant .hereby, affirms that this darn) is correct :Md.:the -0MOunt .snown is:00*d .0/riling, and the applicant retpostS that a: replacement Warrant/check IS isSued to hirhprinti) sum of $ 8,069.86 (4) . The .JOrrahtIeheele •:.,9.1allable, .01)Wor - any other 'as originally issued, (5) Subscribed and sWortitO 0 .efoeo me day of ka el-20y/ . NOTA Y PUBLIC DONNA MOIR oEnmission expires: Nolty Public - State of Arizona \q My MAR1COPA Commission COUNTY Expires (seal) t c June 19,2022 -1./VartantiChe6k Number 3010025318 (if:kitewn) (6) :Original 'pate of Issue 31-Jan-2019 (if known) (7) Ron fa Original issUe Of Wattarit/Check (8): b Payroll :Eck:services or Goods furnished Li Treasurer's refundlpayment, _ Other: Overpayment Of WIC Special Projects Contract ADHS 14-053007 LI? O d S.3 )_ • a4)0/4 19 (1 .%,aaS 111I11 ARIZONA DEPARTMENT OF HEALTH SERVICES IF illicHL // To Whom It May Concern: Lori Lopez, Assistant Controller, is authorized to sign on behalf of the Arizona Department of Health Services. Lori Lopez has signed the attached Affidavit for Check # 3010025318. Please let me know if you have any questions or concerns. Thank you, Kevin Guimond, MBA Controller Arizona Department of Health Services 150 N. 18th Avenue, Suite 260, Phoenix, AZ 85007 Direct 602-542-2992 Email Kevin.Guimond@azdhs.gov Health and Wellness for all Arizonans Douglas A. Ducey I Governor Cara M. Christ I MD, MS, Director 150 North 18th Avenue, Suite 500, Phoenix, AZ 85007-3247 P I 602-542-1025 F I 602-542-1062 W I azhealth.gov Health and Wellness for all Arizonans