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2O1 ! DEC -5 PM 14: 07 Memo 7o: Fran McCarroll, Clerk of the Board VC' EC] Linda Greinke Bate: December 5, 2018 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 Linda Greinke. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate 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: EtDuplicate 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. 6naciaailrifarit Evv (n (1), being first sworn, upon oath deposes and says: On or about 11 i141,,X) Fs-- (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 $ 450 .97 .(3) Signed: 4-rod-) ts2_,A Qq< (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) Subscribe and sworp_tp before me this <10 day of k \feniabe20 • awl) NOTARY PUBL OFFICIAL SEAL My com75ionipires: NOTARY EMILY PUBLIC CASE - ARIZONA .7 (fi My Comm. MARICOPA Evires COUNTy June 18;1022 . :Real) a:ae;aa f=e Warrant/Check Number (xi (if known) (6) Original Date of Issue (if known) (7) I k-11+-zol (i•—: Reason for original issue of Warrant/Check (8): CO Payroll O For Services or Goods furnished APPROVED O Treasurer's refund/payment 17a43/ O Other: DOART) CY= SUPERVISORS MARCOPA COUNTY Revised April 2015 A.R.S. 11-632 & 11-644