REDACTED - MEDICAL SOCIETY BUSINESS SERVICE INC.PDF

v
MAR) COPA
COUNTY

Office of Budget & Finance
301 W. Jefferson St., 9* Floor
Phoenix, Arizona 85003

P: 602-506-3561
F: 602-506-4451

Maricopa.gov

To: Clerk of the Board

From: Office of Budget & Finance, Accounts Payable
Date: 1-24-2025

Subject: Affidavit — Replacement of Lost Warrant

Please find attached one Affidavit for a 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.

e The original warrant is presumed lost.

Please call Walter Chang at 506-8747 if you have any questions. Please return the
approved Affidavit to my attention in the Office of Budget and Finance, 9" Floor.

Thank you.

Re: Fund: 219 / D190 - County Attorney / vendor name : Medical Society
Business Service Inc

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: CO Duplicate or = Stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

Medical Society Business Services Inc(1) being first sworn, upon oath deposes and says:
Name/Claimant

On or about 11/27/2023 (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

aoe him/her in the sum of g46.24 (3)
Signed: (4)

Print name: (requited) NOE Cami, Le

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 7 day of Jani il 20.2.5,

NOTARY PUBLIC casaaanaee
‘eci ; areathtnean tara
My commission expires: NO. Ta
po ; Expires May 16, 2028
Shu-log Oe (seal)

Warrant/Check Number |Q90003010167066

oem 11/27/2023

Reason for original issue of Warrant/Check (8):
O Payroll

(J For Services or Goods furnished

O Treasurer's refund/payment

Other: Victim Compensation: 1974593-1-rqst8

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc
Revised 100518 ARS. 11-632 & 11-644

SIERRA OUTSOURCING SOLUTIONS
4600 Kietzke Lane, B119 Telephone (775) 333-5757

Reno, Nevada 89502 Fax (775) 333-5747

ACA Ss ERRA 4-800-992-0377

INTERNATION AL OUTSOURCING SOLUTIONS

January 7, 2025

Please be advised that Vanessa Ramirez has authority to complete the Affidavit regarding
Khiry D. Kelly on behalf of our company, Sierra Outsourcing Solutions dba Collection
Service of Nevada as she is a Certified Collection Manager.

Please let me know if you have any questions.
Christie C. Munoz

ie é i
yous f

Legal Department Manager

I convorerce wens “TREASURER OF MARICOEA COUN, SSS WARRANT NUMBER

PHOENIX; ARIZONA 9°: : » 3010167066
DATE , 3
1127-2023 91-2/4221 5
So UNS 3
Forty Six And 24/100 Dollars ia
y ‘ $46.24 3
PAY TO THE ORDER OF 3
. . . AMOUNT E
Medical Society Business Services Inc 5 i $
BUREAU OF MEDICAL ECONOMICS 7 2

one 365 Days sinh op.

Eek ANCIAL OFFICER &

For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV NOT NEGOTIABLE i
MARICOPA COUNTY DEPARTMENT OF FINANCE i
RETAIN THIS FOR | PAYEE, WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS

Medical Society Business Services Inc 3010167666 11/27/2023 346.24
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
OCO000E8354iK 1974593-1-rqst8 GAXIF D190 240000011115 46.24|CA i

240000011115 |

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