STAMPED & REDACTED-WEST VALLEY HEALTH EQUITY.PDF

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: 08.08.25

Subject: Affidavit — WEST VALLEY HEALTH EQUITY

Please find attached one Affidavit for a Duplicate Dated 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 Marcia Anderson at 506-7291 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: D860-PUBLIC HEALTH-FUND 296 — FY26-26-00076 ARPA EXPANDED TESTING SERVICES FOR
STD — LN, 26*2136

MAR COPA
COUNTY

This application is for

Application for a Duplicate or Stale Dated
eeniniananin Affidavit/Clainm Forna

Loupticate or |_| state-Dated (definitions are on page 2)
P

STATE OF ARIZONA

COUNTY OF MARICOPA

Dest veel ey enlin

Note: Numbers on this fer correspond to the numbers
on the Instruction sheet which is page 2 of this form

G, aut

eT
l

On or about

(1), being first sworn, upon oath deposes and says:

can (2) a warrant/check was issued to the above named

person/entity I in nthe amount 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 joauesss that a replacement warrant/check

be issues to him/her in the sum of $_4 21 T3Y. OO . (3)
Signi yorLA Can YR NP Pet Bower dy ok bieehos
Print Name: (required) A lie Ce Mvaera Roe enc Qeart— tre bred A SveetwS

Note; Please attach a copy of the warrant/check ‘i available and/or any other evidence that a
warrant/check was originally issued.

(5 ») Subscribed and s ween to, to before me this ae day of AL ey Lod © 201.

ale Clr per fe a)

NOTARY PUBLIC ty , P '
eo a TIEN TERESA $ FLOYD
X > ae j; X Notary Public - Arfzona
a OY 7 . Haricopa County
My commission expjres: _ “ Y commission #830149
G24 tadls in
2a

IWarrant/Cheok Number
{if known) (6)

Original Date of Issue

46 | 62 |foFl}
(if known) (7)

8/8/25
ate of Is f° (0 Jods : -
Reason for original issue of Warrant/Check (8):

(Payroll
Ja For Services or Goods furnished SIO tesking C- “Be-24 OO" GO?
Pik RFP Z2024

(1) Treasurer's refund/payment

C] Other. _ Fund 296 - D860-Public Health- FY26-26-00076 ARPA Expanded Testing Services

LN. 26*2136 for SFB

S:\PROCESSES\Warrants - Duplicate or Stale\O2 Forms\Current Claim Fosm\100518 Warrants Checks notice of claim.doc Revised
100518

ARS. 11-632 & 11-644

West Valley

ALALTH EQUITY
Where Health Meets Home

Subject: Request to Stop Pay on Warrant and Reissue Payment

To whom it may concern:

|, Teresa Floyd, authorize Julie Carlberg. President. Board of Directors, to execute an
affidavit on behalf of West Valley Health Equity.

Please contact me if you have questions.

Thank you,» Jf

\
Teresa Floyd, COO

COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER
PHOENIX, ARIZONA 3010216914

ran DATE

Fifty Two Thousand Seven Hundred Thirty Nine And 00/100 Dollars

$52,739.00
PAY TO THE ORDER OF
. AMOUNT
West Valley Health Equity
Void After
365 Days
Por Questions ~ 602-506-1379 or email AP@MATE.MARICOPA.GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR. RECORDS
West Valley Health Equity 3010216914 O7/11/2025 $52,739.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT

04-2025-2026 01-2025-2026 DO D860 260000000233 | 260000001558 52,739.00

(I) Agency | Status Warrant number — lssued date Paid date Amount

Issued

FAVS 2025

Warrant urbe

Amount Payee Account

t Valles Health Equity Po