STAMPED & REDACTED CHAYLA N. HIRZ.PDF

Maricopa County
Human Resources
1202
Memo Ud¥
L2 15 5:
To: Cindy Goelz, Clerk of the Board
LZ:01WY
From: Daniel Villalba (MHR)
Date: April 27, 2021
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 Daniel. at ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.
Stale Dated Warrant Duplicate Warran
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: Duplicate or [] stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
Instruction sheet which is page 2 of this form.
COUNTY OF MARICOPA
Chayla N. Hirz (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 4/14/2021 (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 $ 1,342.33 (3)
(. Ha— (4)
Signed:
Note: Please attach a copy of 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 20° day of Ror { 2021 .
ad Aah MA LLWA?
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NOTARY PUBLIC
SALINA M VALENTIN
Notary Public - Arizona
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Warrant/Check Number OSLB0S FF bd
(if known) (6)
Original Date of Issue [2021
UfIM
(if known) (7)
Reason for original issue of Warrant/Check (8):
im Payroll
C For Services or Goods furnished 04/27/2021
1) Treasurer's refund/payment
O Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644

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