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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 211212 JAN13 Pil It: 04 INTEROFFICE MEMORANDUM Date: January 13, 2020 To: Clerk of the Board From: Walter Chang Department of Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached 1 Affidavits for lost warrants to be included on the next available Board Agenda. • The attached items have been researched to ensure the warrant in question have not been cashed or previously re-issued. • The original warrants have a void/stale date/stop payment done. Please call me at 506 - 8747 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. Re: Fund: 675 / Dept: D750 / RISK MANAGEMNT / Company: THOMAS C WILMER PC a NOTARY PUBLIC BAMBI L. SEASE Notary Public, State of Arizona Maricopa County Commission # 565105 My Commission Expires June 28, 2023 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or LI Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is paae 2 of this form. THOMAS C WILMER PC Name/Claimant On or about 17 -Dec-2019 (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 $ 584.45 .(3) Signed: ti\k; (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally Issued. Subscribed an sworn to before me this C?-i-h day of Fcrii3Ateths)--- (1), being first sworn, upon oath deposes and says: (seal) Warrant/Check Number (if known) (6) 3010050064 Original Date of Issue (if known) (7) 17-Dec-2019 Reason for original issue of Warrant/Check (8): LI Payroll For Services or Goods furnished I related to statutory issue LI Treasurer's refund/payment LI Other: JAN 1 b. 2020 THOMAS C. "WILMER, P.C. Attorney at Law 2504 N. Third Street Phoenix, Arizona 85004-1308 Telephone: (602) 230-1188 0 Facsimile: (602) 264-9895 Email: TornO)WiimerLaw.corn January 8, 2020 Maricopa County Finance Department Accounts Payable Attention: Walter Chang 301 W. Jefferson Street, Suite 960 Phoenix, AZ 85003 Re: Stephen Roth v. Maricopa County ICA Claim No.: 20033-280127 Carrier Claim No.: WCMAR2003420100 Date of Injury: 10/28/2003 Dear Walter: I, Thomas C. Wilmer, authorize Kristine Bergstedt, my Legal Assistant to execute an Affidavit for THOMAS C. WILMER, PC concerning lost check number 3010050064. Very truly yours, Thomas C. Wilmer, President THOMAS C. WILMER, PC TCW:kjb Enclosure