STAMPED & REDACTED SUNRISE MOUNTAIN HEALTHCARE INC..PDF

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

This application is for: Duplicate or O 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

paae 2 of this form.
SUNRISE MOUNTAIN HEALTHCARE INC (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 14-Jan-2022 (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/check be issued to him/her in the sum of $ 8,588.98 .(3)

Signed: G Wes. ard A, fille Mendez (a)

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 ayo QU MN 20da.
SAC MATRA,
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NOTARY/PUBLIC © V~ // >” Soe OF
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Man. {3 2027 41, Oag Pires WO” (seal)

Wi t/Check Numb
arrant/Check Number 13940107719

Original Date of Issue
(if known) (7) 14-Jan-2022

Reason for original issue of Warrant/Check (8):
O Payroll 03/21/2022

For Services or Goods furnished

C1 Treasurer's refund/payment
O Other:

Rio Vistar SOMME RCE

POST ACUTE & REHABILITATION , SENIOR LIVING

3/17/22

|, Megan Majors, authorize Albert Mendez, Operations Manager to execute an affidavit on behalf of
Olive Ridge Senior Living.

Yours truly,
Megan Majors

Executive Director