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RECEIVED —Hhtedusccee AUG 04 2020 BIC (Sse MARICOPA COUNTY MARIGOPA COUNTY Loss Department of Finance CLERK BOARD OF SUPERVISORS ( ara ( 301 West Jefferson, Ste 960 CoGNsA Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: August 4, 2020 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit - Replacement of Lost Warrant Please find attached affidavit for lost warrant to be included on the next 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 has a void/stale date/stop payment done. Please call me at 506-1329 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Re: EXAMWORKS FUND 675 DEPT 750 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or CO 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. EXAMWORKS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 02-Jan-2020 (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 $. 10,370.00 .(3) Mire! (4) Note. fieash attach opy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Signed: (5) Subscribed and sworn to before me this _aAY ve day of nen 200 NOTARY PUBLIC KATHERINE HOFLAND MARICOPA COUNTY My Commission Expires (seal) September 22, 2020 My commission expires: 9(2.212. 020 Warrant/Check Number | 3949950919 (if known) (6) Original Date of Issue (if known) (7) 02-Jan-2020 Reason for original issue of Warrant/Check (8): O Payroll O For Services or Goods furnished OO Treasurer’s refund/payment Other; Risk Management claims (3% Works) July 23, 2020 I, Julie Nieman, authorize Kimberly Hernandez, General Manager, to execute an affidavit on behalf of Exam Works. Ul jie Nieman Accounting Manager e199) Works ExamWorks 3280 Peachtree Rd NE Suite 2625 Atlanta, GA 30305 Direct: 404-836-9012 Fax: 503-796-0010 www.examworks.com 2525 SW First Avenue © Suite 115 © Portland. OR 97201 = Phone: 800.388.2775 » Fax: 503.796.0749