STAMPED AND REDACTED - 3010231967 - MARICOPA COUNTY HEALTH CARE DISTRIBUTION.PDF
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To: Clerk of the Board From: Office of Budget & Finance, Accounts Payable Date: 5/19/2026 Subject: Affidavit ― Replacement of lost warrants Please find attached 1 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. • The original warrant is presumed lost. Please call Joyce Maurmann at 506-1343 if you have any questions. Please return the approved Affidavit to my attention in the Office of Budget and Finance, 9th Floor. Thank you. Re: Warrant #3010231967/ MARICOPA COUNTY HEALTH CARE DIST Fund 296 ― D950 PRM 260000024265 Office of Budget & Finance 301 W. Jefferson St., 9th Floor Phoenix, Arizona 85003 P: 602-506-3561 F: 602-506-4451 Maricopa.gov MAR COPA COUNTY Application for a Duplicate or Stale Dated Warrant/Check Affidavit/Claim Form This application is for EJ Duplicate or D Stale-Dated (definitions are on page 2) ST ATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to the numbers on the Instruction sheet which is page 2 of this form MARICOPA COUNTY HEAL TH CARE DISTR (1 ), being first sworn, upon oath deposes and says: Name/Claimant On or about Jan 23, 2026 (date) (2) a warrant/check was issued to the above named person/entity in the 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 requests that a replacement warrant/check be issued to him/her in the sum of $207,989.60 . (3) Signed: vVI (4) Print Name: (required) M,, C\ r\:\:L,\-Y u, ; u Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) t 3010231967 Jan 23, 2026 Reason for original issue of Warrant/Check (8): JEZABEL TAUTIMES Notary Publlc • Arizona Maricopa County Commission # 644990 Feb 14, 2027 /r-,a:,.:a,,----@-A--=::, □Payroll __________________________ _ □For Services or Goods furnished __________________ _ □Treasurer's refund/payment ___________________ _ 0 Other: MC-ARPA SOAR (BH) Program S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\ 100518 Warrants Checks notice of claim.doc Revised 100518 A.RS. 11-632 & 11-644