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Maricopa County Human Resources To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: August 29, 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 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: gl 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 page 2 of this form. Amanda Sanchez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 08/21/2019 (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 $ 263 .59 .(3) Signed: Amanda Sanchez (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 2-1 44.\ day of /1-1441.AS4 20 (9 . NOTARY PUBLIC CHRISTINE E. SRP Notary Public, State of Arizona My commission expires: Maricopa County o My Commission E)5pireA , May 09, 20Z.eaU Warrant/Check Number 0022670102 (if known) (6) Original Date of Issue 08/21/2019 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll CL 0 For Services or Goods furnished GI Treasurer's refund/payment Other: Did not receive in the mail Revised April 2015 A.R.S. 11-632 & 11-644 Maricopa County Human Resources Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix, AZ 85003-2143 DATE: 7M, L'1 Phone: 602-506-3519 Payroll Fax: 602-372-0277 Records Fax: 602-506-5509 TO: Eileen Williams wvAv.maricopa.gov FROM: Lti 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: 602-'20) 07 Warrant Number: Issue Date: s ig Payable to: Amount: Reason for Stop Payment: Attach a print screen of the paycheck view. Authorized Signature — Payroll Specialist Date Stopped g' Stopped by cr-Datcl 94Time Transaction Number Stopped