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keS MARICOPA COUNTY C LE BOARD OF SUPERVISOR' Department of Finance 1-1ARICOP A COUNT 301 West Jefferson, Ste 960 2016 JAN 20 AM 8: 314 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: January 20, 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: CRITICAL NURSING SOLUTIONS Application for a Duplicate or Stale-Dated Warrant/Check 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 bade 2 of this form. CRITICAL NURSING SOLUTIONS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 14 -Dec-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 himifig-in'tTie sum of $ 3,482.01 .(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) Subsc 'ed and swora to before me this day of janoeRi 20 / t. NOTAW PUBLIC Agnes Latuner-Soto Vtary Public, State of VW 9int My commission expires: No. 011.916183916 Quafifted in Queens Comfy /1,2//c, Commission EATires May 12, 20I7, (seal) Warrant/Check Number 360013607 (if known) (6) Original Date of Issue 14-Dec-2015 (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll F1 For Services or Goods furnished during the month of November, 2015 0 Treasurer's refund/payment n Other: AA giteeivie-6 APPlitO*LiJi DAT JAN 1 2016 /11111MM7..A4... K BOARD OF SUPERVISORS MARICOPA COUNTY CNS Critical Nursing Solutions, Inc. 1983 Marcus Ave Lake Success NY 11042 January 12, 2016 Warrant # 360013607 To whom it may concern: Please accept this letter as I am the authorized signer to sign for the business entity Critical Nursing Solutions. DavITRimbell Chief Financail Officer 516-750-1733 1983 MARCUS AVENUE • Suite E-122 • LAKE SUCCESS, NY 11042 • (516) 750-1633 • FAX (516) 750-1750 TREASURER or MAR1COPA COUNTY PHOENIX,ANZONA 0'4 12(2.9(a5, 003;50013607 oft=e4t.koe*k.h'kk*kk*kAkAA,k0,AiteAkkAi*RA.AtTHREt THOUSAND Joh.tc, tUA NA **** * k* k FOUR HUNDRED EIGHTY TWO DOLLARS AND 01 /10 Oil; _ PA‘00 OM-AS oF• ,*3, 482 , 01 ,AhAwNT CRITICAL NURSING SOLUTIONS 2200 EAST •AmELsAcK ROAD SUITE 230 PHOENIX AZ 85016 QUESTIONS - E02-506-1375 OR APOMAIL.NARICOPA.GOV mikolOtt" CA'xiM1',i-- bP41 04, 1- mAtiog NOT NE cal lAa Le , - ,•;,-;,-,, ,sA,,..-,i-oi- - "7,,viA40ii .-' ' ' - '1 ' -, 1 c CRITICAL NURSING SOLUTION I 0 03 600 13 6 , 01 12/14/15 ovvol Wet PDXMPIKw Ptipt*OqW ORMiA O • VOW:MLR NO i A1,10k,Mt 1150022193 cH B-TEMP NURSING WE 11./14 16262040014 262000058.4 976.38 1150022-193 DT s couNT TAKEN 16262040014 ?i62620000-584. 19.52T 1150022703 CH S-TEMP NURSING WE 11/21 182 62040011 ip2620D.00584 837.25 = 1150022703 1 DISCOUNT TAKEN 1 626204 0014 ;62 62oop05ag 12.744- 1 1150022703 CHB-TEMP NURSING W/E 11121 16262040019 6262001a0S8d 598.00+ 1 1150023142 CHB-TEMP NURSING W/E 11/28 162 62010019 *262000058 -$ 2,655.751 1150023142 DISCOUNT TAKEN 18262010014 526201000534 53.11'- 1150023142Ci CH S-TEMP NURSING WIE 11/28 16262040014 82€20000.5a 104.00i- 't`• 40:40