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MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: November 12, 2015
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. (3
C.
• The original warrant has a void/stale date/stop payment done. > A.,
- CD Z-3
-
Please call me at 506-1329 if you have any questions. Please return the approved-2,'
Affidavit to my attention in the Department of Finance, Suite 960.
1
CA, (./1
Thank you. (fl A.)
Re: PMA CONSULTANTS LLC
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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.
PMA CONSULTANTS LLC (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 01-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/chec im/her in the sum of $ 7,475.00 .(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) Subscribed and sworn to before me this 0I.' day of S\ 20
_
NOTARY PUBLIC
BARBARA F CABLE
NOTARY PUBLIC • STATE OF MICHIGAN
My commission expires: COUNTY OF WASHTENAW
MY COMMISSION EXPIRES OCTOBER 17,2020 (seal)
Warrant/Check Number 360005323
(if known) (6)
Original Date of Issue 01-Sep-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll Cr7-7r-7-: MARICOPA I3.0AAD't7rP.. COUNTY
• For Services or Goods furnished during November & December, 2014
El Treasurer's refund/payment
El Other:
PHI
PMA Consultants 226W. Liberty Street • Ann Arbor, MI 48104
AMMilaafl Tel: 734.769.0530 • Fax: 734.663.9561
November 6, 2015
County of Maricopa
Department of Finance
301 W Jefferson, Suite 960
Phoenix, AZ 85003
Re: Signature Authorization
Dear Ms. Brown,
Please use this letter as authorization for Kirsten Sell to execute any and all documents required for
contract agreements between the County of Maricopa and PMA Consultants LLC.
Please see her signature here:
Thank you.
Sincerely,
Gui Ponce de Leon, CEO
PMA Consultants LLC
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