041118 STALE DATED WARRANTS 5.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003 JW
INTEROFFICE MEMORANDUM
Date: November 28, 2017
To: Clerk of the Board
From: Nadine Higuera
Department of Finance
Subject: Affidavits —Stale-Dated
Please find attached 1 Affidavit for stale-dated to be included on the next available
Board Agenda.
• The attached item has been researched to ensure the warrant in question
have not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please call me at 506-1354 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re:
Chandler
Regional
Medical
Center

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for; 0 Duplicate or 0 Stale-Dated (definitiorrs are on page 2)
STATE OF AR[ZONIA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the h-Istruction sheet which is
page 2 of this form.
Chandler Regional Medical Center (1), being first sworn, upon oath deposes and says:
Name/Cialmant
On or about 14-Jun-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/chec be issued to him/her in t e sum of $2,567.1s. .(3)
Signed: (4)
Note: Please attach a copy of the warranVchecic if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this 5day of /000 20 1 7.
VALERIE G P1TRE
My commission expires: NOTARY PUBLIC - ARIZONA
I MARICOPA COUNTY (seal)
My Commission Expires
Warrant/Chock Number 360029099
(if known) (6)
Original Date of Issue 14-Jun-2016
(if known) (71,
Reason for original issue of Warrant/Check (8);
0 Payroll
NI For Services or Goods furnished
0 Treasurer's refund/payment
ID Other:
NOV 2 t 201;'
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