052318 STALE DATED WARRANT 2.PDF

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MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: April 26, 2018
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
SCOTTSDALE SURGERY CENTER LLC
Please find attached 1 Affidavit for a 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 warrants have a void/stale date/stop payment done.
Please call me at 506-7291 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or 1:1 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
Dacte 2 of this form.
SCOTTSDALE SURGERY CENTER LLC m being first sworn, upon oath deposes and says:
Name/Claimant
On or about 02-Dec-2016 (clate)(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 Ye-i8-gt him/her in the sum of $ 6,690.80 .(3)
Signed: (4)
Note: P ase attach a copy of the warrant/check if available and/or any other
eviclençé that a warrant/check was originally issued
(5) ed and sworn to before mthis (54 day of 20
°L (r Cik
ARY PUBLIC
My commi,ssior7xpires: Notary Public State of Arizona
fo)- Torn Maricopa I Shields County (seal)
My Commission Expires 08128/2018
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Warrant/Check Number 1 370011186
(if known) (6)
Original Date of Issue 02-Dec-2016
(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: Stale Dated/Lost Warrant