STAMPED & REDACTED - BANNER ALZHEIMERS FOUNDATION .PDF

301 West Jefferson
Phoenix, Arizona 85003

INTEROFFICE MEMORANDUM

Date: January 6, 2023
To: Clerk of the Board
From: Walter Chang

Office of Budget and Finance

Subject: Affidavits — Replacement of Lost Warrants

Please find attached 1 Affidavits for lost warrants to be included on the next available

Board Agenda.
e The attached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.

e The original warrants have a void/stale date/stop payment done.

Please callme at ~ if you have any questions. Piease return the approved
affidavits to my attention in the Office of Budget and Finance.

Thank you.

Re: Fund: 296 / Dept: Human
Services / Company:
Banner Alzheimer's
Foundation

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: Duplicate or (J 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
page 2 of this form.

Banner Alzheimer's Foundation (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 17-Nov-2022 (date)(2) a warrant/check was issued to the
above named person/entity in the arnount 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

seen (bh issued to him/her in the sum of $/5, 000.00 (3)
Signed: lis A v (4)

Note. Please attach a cop; Yy 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 _<27 day of [22C2nitae’ 20d,

NOTARY PUBLIC \’ AAA Publo State of ANZORA
Lisa
My commission. expires: > Se Wy oman exes 78
J-J-2OR3 (seal)
Warrant/Check Number 1900003010134282
Original Date of Issue
(if known) (7) 17-Nov-2022

Reason for original issue of Warrant/Check (8): 1/09/2923

O Payroll
O For Services or Goods furnished

O Treasurer's refund/payment
Other: Serial: RFP-220301, PO# 220301, Project ECHO Dementia - Detailed Project Pian, First Report Invoice

ga) 7
oe Banner Phoenix, AZ 8501.2

Health Foundation &
Alzheimer’s Foundation

December 28, 2022

|, Ms. Andy Kramer Petersen, authorize Ms. Katie Penkoff, Director of Foundation Relations, to execute an
affidavit on behalf of Banner Alzheimer’s Foundation.

Most sincerely,

Ms. Andy Kramer Petersen
President and CEO

Banner Health Foundation
Banner Alzheimer’s Foundation