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Maricopa County Human Resources Memo From: Linda Greinkeit Date: October 10 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 G. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220 Stale Dated Warrant Duplicate Warrant Thank you. RECEIVED-taunt OCT 1 0 2019 MARICOPA COUNTY Replacement Lost Warrant Form CLERK BOARD OF SUPERVISORS 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 1)uplicate 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. Rir,rdidia SkdezZ (1), being first sworn, upon oath deposes and says: ame/Clainnant On or about (date)(2) a warrant/check was issued to the above named person/ nti 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_lassuej to him/her, in the sum of $ o 5. 3Z .(3) Signed: (--r) (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 10 day of OCA- 20 . My commission expires: It • ci • 30.aa (seal) Warrant/Check Number Q. a6-77 q13 (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): OCT 14 2019 Payroll DA I E 0 For Services or Goods furnished 0 Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 81. 11-644 (loa - Do al& 6(ocitf LP-41—