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Maricopa County Human Resources 7ic") 54— e- ro ro .p• .7j r- rn Memo 72 %) • 711 CJ1 CP . To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: January 22, 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 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 D 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. Hope Medina (1), being first sworn, upon oath deposes and says: Name/Claimant On or about November 28, 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 issued to him/her in the sum of $ 219.70 .(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 day of 20 MARIA XANttR My commission expires: Notary PlbIic c -O`)-(-) My December Commissiod!ExpIres 18,U20 (seal) • .Maricope County Warrant/Check Number if known) (6 22620654 Original Date of Issue (if known) (7) 11/28/2018 Reason for original issue of Warrant/Check (8): Payroll For Services or Goods furnished Treasurer's refund/payment [Ti Other: Revised April 2015 A.R.S. 11-632 & 11-644