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CLL i) OF iUER CO !,1 NI Y Maricopa County Human Resources 2013 MAI -2 AM (no 10: 29 Memo To: Fran McCarroll, Clerk of the Board From: Debra Upton 5ate: May 2, 2019 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 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: D/ plicate 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. Doy1414 L. 4:II (1), being first sworn, upon oath deposes and says: Name/Claimant On or about I/ d / I q (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/checlued 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 2 day of 1-1VM 20 19 . Bi-u24_11)(11:1afyyv-AAn NOTARY PUBLIC EILEEN WILLIAMS. Notary Public - Stale ofArbscria My commission expires: MARICOPA COUNTY 1 • 30,). Expires Commission November 554349 9, 2022 (seal) Warrant/Check Number (if known) (6) so> Original Date of Issue (if known) (7) ReasDP for original issue of Warrant/Check (8): Payroll 0 For Services or Goods furnished 0 Treasurer's refund/payment 0 Other: A P 0 V ED Revised April 2015 A.R.S. 11-632 & 11-644