REDACTED - FOR AGENDA ATTACHMENT - SONORA ORTHOPAEDIC TRAUMA SURGEONS.PDF
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v MAR) COPA COUNTY Office of Budget & Finance 301 W. Jefferson St., 9* Floor Phoenix, Arizona 85003 P: 602-506-3561 F: 602-506-4451 Maricopa.gov To: Clerk of the Board From: Office of Budget & Finance, Accounts Payable Date: 5/13/2024 Subject: Affidavit — Replacement of lost warrants Please find attached 1 Affidavit for a stale dated 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. e The original warrant is presumed lost and is stale dated. 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, 9" Floor. Thank you. Re: Warrant #3010120502 / SONORAN ORTHOPAEDIC TRAUMA SURGEONS Fund 268 — D190 GAXIF 220000018709 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: O Duplicate or 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. being first sworn, upon oath deposes and says: Sonoran Orthopaedic Trauma Surgeons (4) Name/Claimant ‘ On or about 21-Jun-2022 (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, er 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 canines $9,875.98 (3) Signed: <a (4) Cc Note: Skece attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5}- "Tor ete sworn to pefore me this _//7 day of Apel 20.24. oie Me DONNA TRENT Notary Public, State of Arizona Maricopa County Commission # 654388 My Commission Expires August 31, 2027 5 (seal) M waner | expires: — Hudust 31,2057 UG Warrant/Check Number 1999003010120502 Original Date of Issue (if known) (7) 21-Jun-2022 Reason for original issue of Warrant/Check (8): D Payroll U1 For Services or Goods furnished O Treasurer's refund/payment Other: Victim Compensation Check: 1812098-1 Request 10 SONOF ORTHOPAEDICS JA KS SAAN April 17, 2024 Maricopa County Re: Authorized Signer To whom it may concern: Our finance manager, Jeana Brady, is authorized to sign for Sonoran Orthopaedic Trauma Surgeons. If further information is needed, please feel free to contact me. Sincerely, Herjinder K. Sihota Chief Executive Officer Sonoran Orthopaedic Trauma Surgeons, PLLC PHOENIX, ARIZONA 3010120502 DATE 91-2/1221 Five Thousand Eight Hundred Seventy Five And 98/100 Dollars EO $5,875.98 PAY TO THE ORDER OF SONORAN ORTHOPAEDIC TRAUMA SUR AMOUNT 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 | PAYER, WARRANT NO. | WARRANT DATE | WARRANT AMOUNT YOUR RECORDS SONORAN ORTHOPAEDIC TRAUMA SUR 3010120502 06/21/2022 $5,875.98 INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT 00000064259K 1812098-1-rqst10 GAXIF D190 220000018709 5,875,98|/CA 220000018709