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Maricopa County Human Resources Memo 5:1:1 ' 57. -5 C) 0- NI -PP cr. To: Fran McCarroll, Clerk of the Board -0 013 rivr- From: Debra Upton Date: January 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 Debbie U. at ext. 66329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate 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 0 Stale-Dated (definitions are on page 2) STATE OF ARIZONA trikt Hirrir correspond (c»:11..rril II (or--11 the COUNTY OF MARICOPA Instruction sheet which is page 2 of this Isirrr ‘rt C ( 1-6\1 ciAiN (1), being first sworn, upon oath deposes and says: Name /Claimant On or about 01) (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/checi4e issued tp-latm/her in the sum of $ 'a . .(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. and sworn to before me this day of .()• 201t. NOTARY/PUBLIC DIEGO FADRIZIO IADNER My commis,sion expires: Notary MAR Public ICOPA - Stale COUNTY ofArizona 6/2//2„91/ My Commission Exp(Sei •" • June 22, 2021 Warrant/Check Number ODL4S 7 (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): El Payroll _o E l For Services or Goods furnished E l Treasurer's refund/payment Other: Corra# cm/ H-pfi tido, Li Revised April 2015 A.R.S. 11-632 & 11-644 MARIOOPA COUNTY