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30,-.FID - CL OF SUPER EM ViSoTS Maricopa County MARICOPA COUiii Y • Human Resources 2019FEB -6 NI 14: 2 14 rTi 0 -Vitiok _A, Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: February 6, 2019 Re: Replacement of Lost Payroll Warrants Please find attached I 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 100D2102120ELEC10000 P21047 Dept: 2120 — Elections 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: 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. Juan Alvarez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about September 19, 2018 (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"ued to him/her in the sum of $ 263.63 .(3) (4) ote: Please attach a copy of the warrant/check if avallabe and/or any other vide ire that a warrant/check was originally issued. i ; ill'ih rr Perld Aannfld IktvAinorrnn ttno hbPeffrcrrPe rnPe m tthhiisq 11 A—I— dri4/ on, fi, 20 1 Miguel Razon Notary Public Maricopa County, Arizona My Comm. Expires 01-24-22 (seal) Warralit/Check N amber (if known) (6) 22603693 Original Date of Issue (if known) (7) 09/19/2018 A DATE 2 A 2 FE 0 720 Reason for original issue of Warrant/Check (8): ig Payroll CLERK, BOARD OF SUPERVISORS El For Services or Goods furnished MARICOPA COUNTY OTreasurer's refund/payment Other: Revised April 2015 A.R.S. 11-632 & 11-644