STAMPED & REDACTED JALAANI THOMPSON.PDF

Maricopa County
Human Resources
To: Cindy Goelz, Clerk of the Board
From: Debbie Upton
Date: April 7, 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 Debbie. at ext. 66329 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.
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Thank you.
Replacement Lost Warrant Form 1 02/25/2015

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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
Jalaani Thompson (1), being first sworn, upon oath deposes and says:
~~ Name/Claimant
On or about 03/31/2021 (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 ¢ 956.14 —_.(3)
signear A WEE, Ue, KM) (4)
nots. brease attadh a of the warrant/check if available and/or any other
copy
evidence that a warrant/check was originally issued.
2024
(5) Subscribed and sworn to before me this_“7___day of Opes .
NOTARY PUBLIC
My commission expires:
(seal)
Warrant/Check Number 0023051687
ene Te
Original Date of Issue 3/ 31 / 21
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished
04/08/2021
C) Treasurer’s refund/payment
(1 Other:
Revised April 2015

ee : Off Cycle: No a
ADP Enterprise HR screen print as of: 04/07/2021 03:04 PM