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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: March 12, 2015 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit — Notice of Claim Please find attached Affidavit for stale dated warrant to be included on the next available Board Agenda. • The attached item has been researched to ensure that 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: Kinect Physical Therapy R NED MAR 1 2 015 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Feb. 11. 2015, 10:03AM K1NECT PT GLENDALE No. 5I7 11:2U1 9:31)AM No. 392/ AFFIDAVIT RECEIVED MAR 0 9 2015 STATE OF ARIZONA COUNTY OF MARICOPA RISK MANAGEMENT 1D,0 fl 111 tL 7--st 11 -11 , on behalf of ICinect Physical Therapy, being first sworn, upon oath deposes and says: That on the 1 day of July, 2013, they presented to Maricopa County, for payment, a claim for services rendered or supplies furnished during the month of May, said claim being in the sum of Two Hundred Seventy Six doilars and Seventy-six cents ($ 276.76) in payment of which the Board of Supervisors caused the Warrant No. 00340001070 to be issued on 07/10/2013, drawn on the expense NM. Affidavit further says that although he/she was informed and believes that the above mentioned warrant was regularly issued, the same ha.s never been received, or has been lost. Wherefore, affiant prays that the Board of Supervisors issue to him/her duplicate of said Warrant No,00340001070 in the sum of $ 276.76. Subscribed and sworn to before me this My commission expires: .3 -10 OFFICIAL SEAL. Return original signed, notarized form to: Notary BOBBI Public L. HAIVIELMAN State of Arizona Marioopa County-Risk Management Dept. My Comm. MAHICOPA Expires COUNTY March 10, 2015 Worker's Compensation 234 N. Central Ave., Suite 530 Phoenix, AZ 85004