101916 DUPLICATE WARRANTS 3.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: October 7, 2016
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached affidavit for lost warrant to be included on the next available Board
Agenda.
• The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: ORTHOPEDIC CLINIC THE

Sep, 2, 2016 10:25AM No, 6621 P. 3
Application for a Duplicate or Stale-Dated Warrant/Check
=EI
Affidavit/Claim Form
This application is for: 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
page 2 of this form.
Orthopedic Clinic Association, The ( 1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 31-Mar-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 in the sum of $ 2,127.16 .(3 )
Signed: (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued,
i 1
(5) Subscribe and sworn to befor me this 6=-14 day of '- 4 20 /6_, .
NOTA0 PUBLIC
STELLA PAVLAK
Notary Public - Arizona
My commission expires: Maricops County
Z(.; ZD 17 My Comm. Expires Jul* 2017 (seal)
Warrant/Check Number 00360022334
(if known)A______
Original Date of Issue 31-Mar-2016
or known) (7)
APPROVEla H
Reason for original issue of Warrant/Check (8): CAP OCT,11 2016
O Payroll
For Services or Goods furnished during Jan and Feb 2016
CI Treasurer% refund/payment
LI Other:
09/02/2016 10:28AM (GMT-07:00)

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Beth Brown - FINX
From: Beth Brown - FINX
Sent: Friday, October 07, 2016 1:25 PM
To: 'MGuerrero@tocamd.com '
Cc: Trade Mobley - RMX
Subject: RE: Check
Hello Michael,
I'll go ahead & submit a copy of this mail with your signed affidavit today.
Thank You,
Beth Brown
Department of Finance/Accounts Payable
Phone: 602.506.1329
Fax: 602.506,3439
Website: http://www.maricopa.gov/finance
From: Tracie Mobley - RMX
Sent: Friday, October 07, 2016 7:24 AM
To: Beth Brown - FINX <brownb002@mail.maricopa.gov>
Subject: FW: Check
Can you please contact them in regards to the letter for the affidavit stating that he is authorized or will this email
suffice.
Thank you,
Tracie
From: Michael Guerrero [mailto:MGuerrero@tocamd.corn]
Sent: Thursday, October 06, 2016 5:34 PM
To: Trade Mobley - RMX
Subject: Check
Hi Tracy,
I spoke with my supervisor regarding the letter/paper stating I am authorized to act for TOCA, and we do not have such
a thing. She said that my signature on this email, as it is on all my other emails, should be enough. However, if needed,
then contact her to verify that I am authorized. Her email is lbauer@tocamd.conn or if you would prefer to talk with her
over the phone about this then her direct line is 602-512-8507. Maybe getting her to verify I am authorized to act on
behalf of TOCA over email and printing it would suffice?
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Thanks,
Michael Guerrero
Reimbursement Specialist
602-512-8480 ext 3510
Fax: 602-266-4842
Serving our Patients through innovative
and comprehensive Orthopedic care.
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and/or its affiliates, are confidential, and are intended solely for the use of the individual or entity to whom this e-mail is addressed.
If you are not one of the named recipients or have reason to believe that you have received this e-mail in error, please notify the
sender and delete this message immediately from your computer. Any other use, retention, dissemination, forwarding, printing or
copying of this e-mail is strictly prohibited.
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