STAMPED & REDACTED ROBIN ANACKER.PDF

RAD IPER ¥iSOR'S ;
A COUNT ¥ Maricopa County
2021 APR-6 PM 12: 49 Human Resources
Viemo
To: Clerk of the Board
From: Zell Bullis
Date: April 6, 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 Zell Bullis at ext. 60409 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220. 4 ov
Stale Dated Warrant uplicate 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: ns Duplicate or C1 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.
Ao loin bWaACKeY (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about _2)17}909) (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 $ 7 V3 | XA (3)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
$7
(5) ed and sworn to before me this _/ day ofefar/ _ 202/.
|
NOPARYPEBLIC™ H
|
Petronia Jackson
My commission expires: ~ Notary Public
8 Maricopa County, Arizona
YA} Ny Comm. Expires May 14, 2022 (seal)
; Commission No. 545940
Warrant/Check Number
23049867
(if known) (6)
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
XJ Payroll
04/06/2021
C1 For Services or Goods furnished : -
O Treasurer’s refund/payment
O Other:
Revised April 2015 A.R.S. 11-632 & 11-644

ADP Enterprise HR screen print as of: 04/06/2021 08:48 AM