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ly\Aoft ckleik MARICOPA COUNTY BOAkD OF CLERK SUPER Department of Finance PIARICOP A COUNTY 301 West Jefferson, Ste 960 2016 JAN 27 AM 9: 214 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: January 27, 2016 To: Clerk of the Board From: Joyce Maurmann Department of Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached 1 Affidavit(s) for lost warrant(s) to be included on the next available Board Agenda. • The attached item(s) has/have been researched to ensure the warrant in question has/have not been cashed or previously re-issued. • The original warrant(s) has/have a void/stale date/stop payment done. Please call me at 506-1343 if you have any questions. Please return the approved Affidavit(s) to my attention in the Department of Finance, Suite 960. Thank you. Re: Cardinal Health - Pharmacy Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: [ 1 1 Duplicate or D 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. CARDINAL HEALTH - PHARMACY (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 08-Sep-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 $24,021.71 .(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. (5) Sub5c-rilled and sworn to before me this 5 )71 day of 201> . NOTYyPUBLIe e .AL6t. CINDY D. FRICKE My commission expires: NOTARY PUBLIC, STATE OF OH! - MORROW COUNTY (s I) ..41- • My Comm. Expires June 7,2016 Warrant/Check Number 360005897 (if known) (6) Original Date of Issue 08-Sep-2015 (if known) (7) APPRAa Reason for original issue of Warrant/Check (8): DATJ D Payroll RK BOARD OF SUPERVISORS For Services or Goods furnished MARIGOPA COUNTY CI Treasurer's refund/payment El Other: Cardinal Health 7000 Cardinal Place Dublin, OH 43017 614.757.5000 main CardinalHealth cardinalhealth.com January 5, 2016 To whom it may concern: I certify that John Wolfe is authorized to sign the Affidavit/Claim Form on behalf of Cardinal Health 411, LLC. Sincerely, Michelle Janlin cc: John Wolfe