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Maricopa County Human Resources 2819 SEP 1 0 Pil 12: 1 9 fr , 0.01 IA-4 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: September 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 Debbie U. at ext. 66329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 1111 Duplicate or El 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 pa ge 2 of this form. cliad (1), being first sworn, upon oath deposes and says: Name/Ulaimant On or about Sol S, 7011 (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 $ 7 .(3) Signed: (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 c7? day of Se/ILI, 20 '\. — NOTARY PUBLIC Meilza Izagulny Notary Public My commissio6 expires: My Mork:oPit Comm. Expires County, Arizona 06-25-22 Lo i-2-S I 21)2_2- Commission No. 549098_ al) Warrant/Check Number 7a2 76.6 (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): NI/ Payroll MARICC)i-iI 0 For Services or Goods furnished 0 Treasurer's refund/payment 0 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