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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: February 5, 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: THE ALARIS GROUP INC Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: v 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 paue 2 of this form. The ALARIS Group Inc. (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 15-Nov-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 request that a replacement warrant/check be issued to him/her in the sum of $ 1,642.53 .(3) Signed :JO ii0kti (kit (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 day of 20 I croisty KRISTINE LOUISE HANSEN My commission expires: 1 • Notary Public II //,'? My State Commission of Minnesota Expires (seal) ) January 31,2021 Warrant/Check Number 3010019772 (if known) (6) Original Date of Issue 15-Nov-2018 ED- (if known) (7) Reason for original issue of Warrant/Check (8): CI Payroll LERK. MARICOPA BOARD OF COUNTY SLTI5ERVISO 0 For Services or Goods furnished 0 Treasurer's refund/payment Other: Settlement for Risk Management ghx iocp i‘s fiSo 6A)6 efd, ALARIS Please accept this document designating Tammy Haapanen as being authorized to sign on behalf of The Alaris Group, Inc. a--b-I*41)1( Patti McKenna Date VP of Finance