SIGNED & REDACTED - GLADYS ARREDONDO MACHADO.PDF

Maricopa County
Human Resources
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ALNAOS S.BOSTAMAdNS
To: Cindy Goelz, Clerk of the Board ar
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From: Debbie Upton
Date: February 12, 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 U. at ext. 66329 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
~ ™
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: PX pupticate or LJ 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.
Avadyys Arveclonde Hachado (1), being first sworn, upon oath deposes and says:
Name/Claimant
02/ oz/ 2024
On or about (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 $ | OF 1-5 | (3)
Signed: Lsedae A . (4)
Mease
Note. 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_ /2. _day of Fels try 202! .
NOTARY PUBLIC
AW LOMAX
Ne Notary Public - State of Arizona
My commission expires: ; Why Ceraiieston Eales
5-19-96 June 18, 2021 (seal)
Warrant/Check Number ,
2 % OU SO | U
(if known) (6)
Original Date of Issue 5 I ps
02/0 3] P02 |
(if known) (7)
Reasopfor original issue of Warrant/Check (8):
Payroll
O For Services or Goods furnished WAIL at
(1) Treasurer’s refund/payment
CL] 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

ADP Enterprise HR screen print as of: 02/12/2021 11:12 AM