STAMPED AND REDACTED - 53369354 - MARC STAMAN.PDF

Maricopa County
Human Resources
Memo
To: Juanita Garza, Clerk of the Board
From: Zell Bullis
Date: September 18, 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: [Z] Duplicate or D Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
_ M .... Name/Claimant a .... rc_s _, ta .,.., m r-, a_n----r ________ (1), being first sworn, upon oath deposes and says:
On or about 711512026 (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 {o, him/her in the sum of $_1 _03_·9_3 ________ .(3)
/, \ ·,
Signed: -+/_\/_l,)_1 _;_{_· __ \=. '_1 _(_l_l,_' i_u,_. _____________ (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
NOTARY P0sLtc
My commission expires: N'==,!. • .... • > e Notary MARICOPA KIM Public• FALCONER Slate COUNTY ol Arizona
J • 22 · c 2, ••.•• &. • • .•• Expires Commission# January 691156 22, 2130 (seal)
Warrant/Check Number
if known 6 53369354
Original Date of Issue
if known 7 7/15/2026
Reason for original issue of Warrant/Check (8):
[{]Payroll
D For Services or Goods furnished _______________ _
□Treasurer's refund/payment _______________ _
Dother: ____________________
Revised April 2015 A.R.S. 11-632 & 11-644