SIGNED SHARON GRETHER FOR 021021 AGENDA.PDF

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BOARD OF SUPE? ViS0R'S Maricopa County
EO Human Resources
9021 JAN-& PM 4: 16
Memo
To: Fran McCarroll, Clerk of the Board
From: Zellnor Bullis
Date: January 4, 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 Zellnor B. at ext. 60409 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: (| 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.
Sharon Louise Grether (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/25/2020 (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
350.00
issued to him/her in the sum of $ (3)
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Signed: — ib (A 5 (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 swoyn to before me this 7 ie day of Leeemhar— 2020.
MW
NOTARY PUBLIC 7” a
My commission expires:
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Warrant/Check Number
23034532
(if known) (6)
Original Date of Issue 24 OM NO CON
11/25/2020 vee
(if known) (7)
Reason for original issue of Warrant/Check (8):
ml Payroll
01/11/2021
C1 For Services or Goods furnished
(1 Treasurer's refund/payment
1 Other:
Revised April 2015 A.R.S. 11-632 & 11-644

Grether,Sharon Louise / Company: MC1 Off Cycle: N
MC1 - Maricopa County Pay Group: ELE Separate Check # 0
Period End 11/15/2020 Reprint: N
Page: 2370 Adjustment: N
Line. 5
( Paycheck View
Name Grether,Sharon Louise Confirmed Check
Check# Issue Date i Taxes Deductions Net Pay
23034532 11/25/2020 350.00
ADP Enterprise HR screen print as of: 01/04/2021 02:02 PM