050615 DUPLICATE WARRANTS - 7.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: April 23, 2015
To: Clerk of the Board r3:4 C=i
2s.
From: Beth Brown
Department of Finance 1‘)
CA)
Subject: Affidavit — Replacement of Lost Warrant
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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: Arrowhead Hospital

AFFIDAVIT RECEWED
APPROVEis APR 2 2 nth
STATE OF ARIZONA RISK MANAGEMENT
COUNTY OF MARICOPA
ERK, MARK:OPA ROARD OF COUNTY SUPERVISO,
Olottva 1404))p k i , on behalf of Arrowhead Hospital, being first
sworn, upon oath deposes and says:
That on the 26th day of February, 2015, they presented to Maricopa County, for
payment, a claim for services rendered or supplies furnished during the month of
October, said claim being in the sum of Sixty-eight Thousand Nine Hundred
Fifty-seven and zero cents ($ 68,957.00) in payment of which the Board of
Supervisors caused the Warrant No. 00350023422 to be issued on 03/17/2015,
drawn on the Expense Fund.
Affidavit further says that although he/she was informed and believes that the
above mentioned warrant was regularly issued, the same has never been
received, or has been lost.
Wherefore, affiant prays that the Board of Supervisors issue to him/her a
duplicate of said Warrant No.00350023422 in the sum of $ 68,957.00.
Signed: hid iROtta
Subscribed and sworn to before me this / day of %,./V , Aws.
My commission expires: ,9..)P4e..4,0 El
P A. MOORE
Return original signed, notarized form to: Notary Maricopa Public County - Arizona
Maricopa County-Risk Management Dept. My Comm, Expires Aug 28, 2015
Worker's Compensation
234 N. Central Ave., Suite 530
Phoenix, AZ 85004