CHAZ MADDOCK.PDF

Maricopa County
Human Resources
C=1 CIZ
CD
To: Fran McCarroll, Clerk of the Board 1"72
CD
From: Debbie Upton
Date: October 17, 2019 1276)
Re: Replacement of Lost Payroll Warrants Lietikt,
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: El Duplicate or 0 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.
Chaz Maddock (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about October 2, 2019 (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 $ 360.17 .(3)
Signed: (4)
Note: Plea* attache a copy oti 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 / / day of 204.
i) 14,11,1(
NOTPfY PUBLIC
My commission expires:
474 eal)
Warrant/Check Number 22677684
(if known) (6)
Original Date of Issue October 2, 2019
Of known) (7)
APPROVED
Reason for original issue of Warrant/Check (8): OCT 8 2019
El Payroll DATE
ID For Services or Goods furnished
Cl Treasurer's refund/payment
El Other:
Revised April 2015 A.R.S. 11-632 & 11-644