041217 STALE DATED WARRANTS 2_REDACTED.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
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INTEROFFICE MEMORANDUM
Date: March 20, 2017
To: Clerk of the Board
From: Nadine Higuera
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 - 1354 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: BANNER OCCUPATIONAL HEALTH

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 12 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
bade 2 of this form.
Banner Occupational Health (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 04-Nov-2015 (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 in the sum of $4,006.96 .( 3)
Signed: A...)cu.-(\_-( (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this day ofe.,/,ceirI 20 17 .
_ 1,J —
NrCTIARY PUBLIC
JANICE L. PADDEN
My commission expires: . w474 NOTARY MARICOPA PUBLIC COUNTY - ARIZONA
NACit.4 , c.:;/ Of 7 My Commission Expires
May 12, 2017
Warrant/Check Number 360010745
(if known) (6)
Original Date of Issue 04-Nov-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
CI Payroll
0 For Services or Goods furnished
0 Treasurer's refund/payment
Other: Workers' Comp payment to provider. Never received.

Bap Ter
Occupational
Health Clinics
Banner Occupational Health Clinics
525 W Brown Rd 8th FL NW
Mesa, AZ 85201
To whom it may concern:
Dioceline Lascano Zambrano has the authorization to act on behalf of Banner Occupational Health for
the purpose of a reissue in payment.
Thank you,
Sabrina Harbin
PFS Supv
Banner Occupational Health Clinics

Page 1 of 1
Warrant 3-6-0010745 Details
Wt Number 3-6-0010745 Wt Amount $4,006.96
Wt Status STALE CANCEL/VOID Wt Interest 0
Acct Num 31-767-000 Issue Date 11/4/2015
Paid Date 11/30/2016 Register Date
Voucher 000 Claim Number 000000
PO Num 000000 Fund Number 767
Dept Num 0000 Low Orig 00000
Payee BANNER OCCUPATIONAL HEAL Sub Fund 000
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https://treasurer.maricopa.gov/Agency/FinanceFunctions/wtlookup.asp 3/20/2017