STAMPED & REDACTED - FOR AGENDA ATTACHMENT - EXAMWORKS INC.PDF

MARICOPA

COUNTY

sonnel

Office of Budget & Finance To: Clerk of the Board
301 W, Jefferson SL, 9% Floor

From: Office of Budget & Finance, Accounts Payable
Phoenix, Arizona 85003

Date: 10.18.24

Subject: Affidavit — EXAMWORKS INC
P: 602-506-3561

F: 602-506-4451

Please find attached one Affidavit for a duplicate warrant to be included on the next

Maricopa.gov available Board Agenda.

e 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.

a Please call Marcia Bulanda 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: FUND 675 — D750 RISK MANAGEMENT ~— WC5005114164434 VILLEGAS — GAX1D 25*2791

Application for a Duplicate or Stale-Dated Warrant /Check

Affidavit / Claim Form

This application is for: Duplicate or (CD state-patea (definitions are on page 2)

COUNTY OF MARICOPA numbers on the Instruction sheet which is
pace 2 of this form.

STATE OF ARIZONA Note: Numbers on this form correspond to |
(1), being first sworn, upon oath deposes and says:

EXAMWORKS INC

Name/Claimant

On or about 15-Aug-2024 {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 destrayed and there is
no reasonable probability of its being found or presented for payment, gr 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 $ 900.00 {3)

Signed: Dobe Wiearou {4)

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 __'t__ day of _ October 20-24.

NOTARY PUBLIC

Bs

ae Rodrick Davis Brownles
My commission, expires: ae hen

COMMISION EXPIRES: (seal)

ao? = Mo,

Wi

rigina Wing 10) J iG 202

’ 10/18/24
Reason for original issue of Warrant/Check (8): Pm

() Payroll
LJ For Services or Goods furnished

CJ Treasurer’s refund/payment
Other: / original check presumed lost in the mail

FUND 675-0750 RISK MANAGEMENT - WG50051 14164434 VILLEGAS - GAX1D 25°2791

Electronically signed and notarized online using the Proof piatform.

CMINTY EXPENSE WARRANT

TREASURER OF MARICOPA COUNTY

WARRANT NUMBER

PHOENIX, ARIZONA 3010190409
DATE
Nine Hundred And 00/160 Dollars
$906.00
PAY TO THE ORDER OF AMOUNT
‘O| c
Void After
365 Days
For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV NOT NEGOTIABLE

MARICOPA COUNTY DEPARTMENT OF FINANCE,

RETAIN THIS FOR ] PAYEE

YOUR RECORDS

WARRANT NO. | WARRANT DATE | WARRANT AMOUNT

EXAMWORKS INC

3010590409 O8/

15/2024 $900.00

INVOICE NUMBER

DESCRIPTION

PURCHASE ORDER NO.

VOUCHER NO. | AMOUNT

491-3132284

WC5005114164434 VILLEGAS

GAX1D D750
250000002791

250000602791 909.00!

October 10, 2024

To whom it may concern:

|, Kimberly Hernandez, authorize Julie Nieman, Accounting Manager, to execute
an affidavit on behalf of ExamWorks.

Please let me know if you need any additional information.

Sincerely,

Kimberly Hernandez

General Manager
Serving the States of AZ, CO, NM, NV and UT

List

F issued warrants sUnsaved fiteri +

oO Agency! Status Warrant number — Issued date
~} Issued paoroigogog y
Fissued 30101 9040S a/15/2024—«120000am 900.00!

Warrant number 301915 040e

Amount Payee Account

S000 EXAMWYORKS INC |