STAMPED AND REDACTED - 53387640 - JENNIFER DICKSON.PDF

Maricopa County
Human Resources
Memo
To: Juanita Garza, Clerk of the Board
From: Zell Bullis
Date: September 9, 2026
Re: Replacement of Lost Payroll Warrants
Please find attached _1__ Affidavit/Notice of Claim(s) for lost
payroll warrants for inclusion on the next available Board agenda.
The attached item(s) have been researched to ensure that the
warrant(s) in question have not been cashed or previously re-
issued. The original warrant(s) have had a stop payment done.
Please call Zell Bullis at ext. 0409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/ Claim Form
This application is for: 0 Duplicate or D Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on th is form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
_JFenGn_ifeHr=DIic_ks__,on,--_______ (1), being first sworn, upon oath deposes and says:
Name/Cla1mant
On or about 811212026 (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, .ru: 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/c im/her . in the sum of $_5_06_·6_3 ________ .(3)
Note: Pleas attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
:::Z
(5) Subscribed and sworn to before me this <iStlA day of AU gust: 20.2..w.
Q. _w:u"Pl eva
NOTARY PUBLIC
FRANCESJEANHANSO Holary Publlc • State of Arizona
My mission expires: Com MAR ICOPA COUNTY
Fe. com1 t-\J<1f' .;zD.3 D B Expires mission Februa # , ijg
30
Warrant/Check Number
(if known) (6) 53387640
Original Date of Issue
(if known) (7) 8/12/2026
Reason for original issue of Warrant/Check (8):
0Payroll
D For Services or Goods furnished ---------------
□Treasurer's refund/payment ________________ _
Dother: ------------------------
Revised April 2015 A.R.S. 11-632 & 11-644