052318 STALE DATED WARRANT 3.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
4:5
Date: April 26, 2018
To: Clerk of the Board
From: Joyce Maurnnann
Department of Finance
Subject: Affidavits — Replacement of Forged Warrants
Please find attached 2 Affidavits for forged warrants to be included on the next available
Board Agenda.
• The attached items have been investigated by Chase bank for forgery,
resolved and funds are returned to Maricopa County.
• The original warrants have paid status, forgery by unknown individual,
vendor never received warrants.
Please call me at 506-1343 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Orthopedic Specialists of N. America

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or D 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
paae 2 of this form.
Orthopedic Specialists of N America (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 12 -Sep -2016 (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 $ 342 - 53 .( 3)
Signed: /Lii, .4t osAo , pzzc (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 0/ day of Aid.,c4,4J 20 t(
NOTARY-PU BLIC
RORY BRIAN RILEY
My commission expires: NOTARY MARICOPA PUBLIC, COUNTY ARIZONA
7---"T -17 My Commission Expires (seal)
July 30, 2019
Warrant/Check Number 370004896
(if known) (6)
Original Date of Issue 12-Sep-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
:11 Payroll
7_1 For Services or Goods furnished
r_11 Treasurer's refund/payment
Other:

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or DI 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
paae 2 of this form.
Orthopedic Specialists of N America (1), being 'first sworn, upon oath deposes and says:
Name/Claimant
On or about 12 -Sep -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 be issued to him/her in the sum of $ 277 -35 .( 3)
Signed: MP, q,(06.1.'W 1)1 1 C (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 Nthit'ifr3c1 20
NOTARY PUBLIC
RORY BRIAN RILEY
My commission expires: NOTARY PUBLIC, ARIZONA
MARICOPA COUNTY seal)
My Commission Expires
July 30, 2019
Warrant/Check Number 370004897
(if known) (6)
Original Date of Issue 12-Sep-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
D Payroll
For Services or Goods furnished
D Treasurer's refund/payment
LI Other: