SIGNED & REDACTED - DOUG BAZER.PDF
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BOP ARicOPR CoUNIY Maricopa County Human Resources 2N21FEB oe IS PM 4:57 . MY Hand Daiud To: Cindy Goelz, Clerk of the Board From: Lisa Platek Date: February 16, 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 Lisa P. at ext. 63619 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: [ml Duplicate or C 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. Douglas Bazer (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 2/3/2021 (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 , 614.63 (3) Signed: A deceglia Loge = (4) 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 | [th day of February 2021 . WHA (wert NOTARY PUBLIC My commission expires: Arpcil 3, 203 (seal) | Warrant/Check Number 0023045021 (it known) (6) Original Date of Issue |02/03/2021 “i known) () Reason for original issue of Warrant/Check (8): im Payroll Ci For Services or Goods furnished | 02/1742021 O1 Treasurer's refund/payment O Other: Revised April 2015 A.R.S. 11-632 & 11-644 Maricopa County Human Resoutces Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix, AZ 85003-2143 DATE: February 16, 2021 Phone: 602-506-3519 Payroll Fax: 602-372-0277 . sae . Records Fax: 602-506-5509 TO: Eileen Williams/ Lisa Platek www.maricopa.gov . FROM: Lisa Plaatek RE: Stop Payment on Warrant Please place a stop payment on the Warrant listed below. It has been determined that the Warrant is outstanding as of this date: Warrant Number: 0023045021 Issue Date: 02/03/2021 Payable to: Douglas Bazer Amount: 1,614.63 Reason for Stop Payment: never received Attach a print screen of the paycheck view. Authorized Signature — Payroll Specialist 21-2 lisa Ratt Date Stopped Stopped by UV Ct 0 Zen Of UOnr- Transaction Number Stopped 23045021 inpaid/Uncashed # M 02/03/2021 Douglas on issued Bazer $1,614.63 SEARCH 202% CHECK