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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: May 26, 2020 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit — Notice of Claim MAY 2 6 202U MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Please find attached Affidavit for stale dated warrant to be included on the next available Board Agenda. • The attached item has been researched to ensure that warrant in question has not been cashed or previously re-issued. • 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: ERIK MESSAMORE MD PHD PC Fund 100 Dept 550 ;&ftIAL s o. ........ . . . P*1 -•—I••1 _ _ - NOTARY PUBLIC My commission expires: Z'-7 Is' NOTARY PUBLIC SSTATE OF OHIO '1 * Comm. Expires 0.6-17-2024 (seal) Recorded in Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Q Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MAR1COPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is pane 2 of this form. ERIK MESSAMORE MD PHD PC (I), being first sworn, upon oath deposes and says: Name/Claimant On or about 20 -Aug -2018 (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 $7,400.00 -(3) Signed: (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 Z2_ day of 20 .zo . '',"74941177 , 30100133u04gr000 Warrant/Check Number (if known) (6) Summit Lountv Original Date of Issue (if known) (7) 20-Aug-2018 Reason for original issue of Warrant/Check (8): El Payroll For Services or Goods furnished Expert Opinion/consultation in Psychiatry 111 Treasurer's refund/payment CI Other: Erik Messamore, MD, PhD Expert Opinion &Consultation Psychiatry, Psychophormacology 22 May 2020 I, Erik Messamore, am the sole proprietor and can therefore sign this affidavit/claim for re- issuance of a stale-dated warrant on behalf of Erik Messamore, MD, PhD. Please mail the re-issued warrant to: Erik Messamore, MD, PhD 626 Franklin Ave, #464 Kent, Ohio 44240 Yours truly, Erik Messamore, MD, PhD Sole proprietor