121317 DUPLICATE WARRANTS 13.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960 2811 f-J'! 23
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
SCOTTSDALE SURGERY CENTER LLC
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: Iv] 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
paele 2 of this form.
SCOTTSuALE SURGERY CENTER LLC. (1), being first sworn, upon oath deposes and says:
Name/ Claimant
On or about 13-Jan -201 7 (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 reasunable probability of its being found or presented for payment, or it was not
present d for payment within one year after the date of issuance.
Therefor 2, under penalty of perjury, claimant hereby affirms that this claim is correct
and the lmount shown is due and owing, and the applicant requests that a replacement
warrant check be issued t er in t sum of $ 8,666.20 .(3)
Signed: (4)
Not ; Pkaattach a copy of the warrant/check if available and/or any other
evici that a warrant/910-0Awas originally issued.
(5) ibed a efor is, day of A4de_ntber 20(7_.
SHEILA PERRY-JOHNSON
Notary Public - Stale at Arkone
My c mmission expires: My MARICOPA Common COUNTY Expires
itiod November 29,2019 (seal)
Warrant 'Check Number 370014552
known) (6)
Original )ate of Issue 13-Jan-2017 P,
It known) (7) KlfflI -D 8 2017
DAT °
Reason Dr original issue of Warrant/Check (8): C:7441114
tz K , R : F t 0
• P yroll MARICOPA COUNTY
.r Services or Goods furnished 0, ViI/iK
O Treasurer's refund/payment
O 0:her: