041118 STALE DATED WARRANTS 4.PDF

110,',Ri) Ur' supLr,
MARICOPA COUNTY riA•":! • 1:
Department of Finance 2111 OCT 16
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: October 16, 2017
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: CHANDLER REGIONAL MEDICAL CNTR

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/ Claim Form
This application is fore 0 Duplicate or 0 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.
Chandler Regional Medical Center (1), being 'first sworn, upon oath deposes and says:
On or about 1 9-Aug-2OI 5 (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, ar 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 tied to him/hr in 'I-the sum of $125.00 ,(3)
Signed: (4)
Note: Please attach a copy of the warranVcheok M available and/or any other
evidence that a warrant/check was ofignally issued.
(5) Subscribed and sworn to before me this day of 20
NOTARY PUBLIC
VALERIE G. PITRE
My commission expires: NOTARY PUSUC • ARIZONA
3 -rt 31 1 l My Commission MARICOPA COUNTY Expires (seal)
January 31, 2017
Warrant/Check Number 360004349
(If known) (5)
Original Date of Issue 19—Aug-20 15
of known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
IR For Services or Goods furnished
0 Treasurer's refund/payment
ID Other;
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