121317 DUPLICATE WARRANTS 11.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
bsi,Jeo
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: November 28, 2017
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
PHOENIX CHILDRENS HOSP MED GRP
Please find attached 1 Affidavit for a lost warrant 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 506-7291 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: IAP2

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: U Duplicate or 151 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
oade 2 of this form.
PHOENIX CHILDRENS HOSP NED GRP (I) being first sworn, upon oath deposes and says:
—NV-7O n° laimant
On or about 30-Dec-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 the sum of $ 41,400.00 .(3)
Signed: (4)
Note: Please attach a oily of the warrant/check If available and/or any other
evidence that a warrant/cifeck was originally issued.
(5) Sub cribed and sworn to before me this /LP ih day of 20 / .
—TCY-MittER- ftti
NOTARY PUBLIC Notary Public - Arizona -An
Maricopa County
My commission expires: 6/My Comm. Expires Aug 18, 2019
f/ l'72-0/ 67 / wilaeogromParmaPoormParmormr%1)
Warrant/Check Number 370013441
(If known) (6)
Original Date of Issue 30-Dec-2016
(If known) (7)
Reason for original issue of Warrant/Check (8): ERK, BOARD OF SUPERVISORS
MARICOPA COUNTY
O Payroll
rk For Services or Goods furnishedA\CA 0 40\1 2010
O Treasurer's refund/payment
O Other: