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V‘kkil‘A 1C)k4)1/4 0Aire OF CLERX• SUPER v ts-ores Maricopa County HARICOT", COUNTY Human Resources 2310 OCT -7 PH 12: 19 Memo To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: October 7, 2019 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 Linda at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant 6 plicate Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Maricopa County Human Resources Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix, AZ 85003-2143 DATE: 10/7/2019 Phone: 602-506-3519 Payroll Fax: 602-372-0277 Records Fax: 602-506-5509 TO: Eileen Williams www.maricopa.gov FROM: Linda Greinke 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: 811121522 2-2/CP176130 Issue Date: 10/2/2019 Payable to: John Novery III Amount: $1041.82 Reason for Stop Payment: never received Attach a print screen of the paycheck view. Authorized Signature — Payroll Specialist Date Stopped 1°1 7/1 9 Stopped by Transaction Number 0 3 3 3 1(,01 Time Stopped ALty) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or 0 Stale -Dated (definitions are on page 2) STATE OF ARIZONA r Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. John M Novey III (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 10/2/2019 (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 iss...u.pd to him/her in the sum of $ 1,041.82 .(3) Signe (4) Note: Please attach 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 7 1- day of 067104er- 20 /9. NOTARY PUBLIC MARC A. LYLES My commission expires: Notary Public-Stateot Arizona g A A• My CormnIssIon MARICOPA Expires COUNTY 410115, 2022 (seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) 14 lit ti 't" Reason for original issue of Warrant/Check (8): El Payroll DATp OCT 49,8 2019 El For Services or Goods furnished El Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644