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Maricopa County Human Resources Memo oe: Zz OO rh ene To: Cindy Goelz, Clerk of the Board ~ one From: Debbie Upton = <3? Date: January 25, 2021 ay Re: Replacement of Lost Payroll Warrants f Q 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: Lx buplicate or L] Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: : Numbers on this form correspond to numbers on the COUNTY OF Instruction sheet which is page 2 of this form. (o Cay Ni [e (0 (1), being first sworn, upon oath deposes and says: Name/Claimant On or about / / G [20 P/ (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, oi 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 $ /, Za?/.? 3 (3) Signed: Wr) Mate L572 (4) Note. Pleasetattach 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 25 dayor_Jam 202 err Cen Wim NOTARY PUBLIC My commission expires: a lees \\ 4-809. mo (seal) Warrant/Check Number = _(if known) (6) oe 304/ 746 = Original Date of Issue r / / b / F021 - (if known) (7) Reason for original issue of Warrant/Check (8): = i Payroll art wo C1 For Services or Goods furnished___ 01/25/2021 1 Treasurer's refund/payment 1 Other: C:\Users\williamse\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\HTTDL74G\Warrants Checks notice of claim.doc Revised April 2015 A.R.S. 11-632 & 11-644 ADP Enterprise HR screen print as of: 01/25/2021 11:51 AM Dept. 270 if sbotrout ‘4