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aoARD OF CI SOPETIVI.C1', EP,r, 'S Maricopa County MARICOPA CO11;i1Y Human Resources 2013 FEB -5 PM 12: 10 Memo To: To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: February 5, 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 Monica at x 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: El Duplicate 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. (1), being first sworn, upon oath deposes and says: ..\41.airrie/CL mant / 17-' On or about I (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 $ .(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 254+‘ day of -3-11-1.3 20 A. au id- AlI-.4I-II•._ NOTARY PUBLIC BRANDI NEDVED-ARNETT Notary Public - State of Colorado My commission expires: Notary ID 20124064055 2.53, 2.(32f) My Commission Expires Oct 29, 2020 (seal) 07.www"IIPM•Nierwwwwqpiwipmir.1 Warrant/Check Number tols (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll CLERK, BOART , 0 For Services or Goods furnished MAR' 0 Treasurer's refund/payment NZ Other: P_ORtAtt VdenegitS Revised April 2015 A.R.S. 11-632 & 11-644