112917 STALE DATED WARRANT 1.PDF

RECEIVED
MARICOPA COUNTY OCT 2 7 2017
Department of Finance
301 West Jefferson, Ste 960 CLERK MARICOPA COUNTY
BOARD OF ri P E- VIVISORS
Phoenix, Arizona 85003
Wke del
INTEROFFICE MEMORANDUM
Date: October 27, 2017
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
CHANDLER REGIONAL MEDICAL CENTER #3600019099
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: E Duplicate or El Stale-Dated (definitions Pre on page 2)
STATE OF ARIZONA Note; Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet whi ch is
Dade 2 of this form,
Chandler Regional Medical Center (1), being 'first sworn, upon oath deposes and says:
175Theiimarst
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 ror 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 i ued to him/her in the sum of $ 2,567 - 18 ( 3 )
Signed: CUCUrt-_..3--s? 61-tiJ (4)
Note,' Please attach a copy of the wan-ant/check if ay-dila/21e and/or any other
evidence that a wan'ant/chP.rk wa.; originOy 15-sued
(5) Subscribed and sworn to before me this clay of Ot.A> 20/
NOTARY PUBLIC
VALERIE G PITRE
fvfly cominissicin expires: NOTARY PUBLIC - ARIZONA
MARICOPA COUNTY (seal)
,n1 My Commission Expires
JANUARY 31 MI__
Warrant/Check Number
if known) (6
01,ginal Date of Issue
if k-nownin 14-Jun-2016
Reason for original issue of Warrant/Check (8):
L; Payroll
`tAl. For Services or Goods furnished
Li Treasurer's refund/payment
El Other:
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