011619 DUPLICATE WARRANTS 8.PDF

Maricopa County
Human Resources
Memo
2-7-3
To: Fran McCarroll, Clerk of the Board Crt
From: Debbie Upton
Date: December 5, 2018
Re: Replacement of Lost Payroll Warrants
Please find attached 3 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.
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: EiDuplicate or Eti 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.
Ki (x%aiman 4aritipes an d (1), being first sworn, upon oath deposes and says:
Name I
On or about /1-1 /2.01% (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/check be issued to him/her in the sum of $ '-103. 20 .(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 „5 day of bec • 2O I.
NOTARY PUBLI
PORTIA M. LOMAX
My commission expir Notary Public- State of Arizona
MARICOPA COUNTY
My Commission Expires (seal)
Juno 15 2021
Warrant/Check Number
(if known) (6) 002.2555L12.6
Original Date of Issue
(if known) (7)
Reasop for original issue of Warrant/Check (8): r-4
LV Payroll I.-'.)
IE I For Services or Goods furnished •••_
I 1 I Treasurer's refund/payment
I Other:
Revised April 2015 CLERK MARICOPA BOARD OF COUNTY SUPERVISOPF A.R.S. 11-632 & 11-649

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: NrDuplicate or rb Stale-Dated (definitions are on page 2)
STATE OF ARIZONA iiikc iiiirririb (cni this )0y-rmi HomripArdi to numbers on --iL
COUNTY OF MARICOPA Instruction sheet is page 2 of this form.
1 'lace( Nambecland (1), being first sworn, upon oath deposes and says:
-- ame Claimant
On or about LI /1g/zoti (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/hej,-,in the surn,of $ Tirl 0. .(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 S day of .r2e 201&_.
chaL
NOTARY PUBLIC oR'rlAM LOMAX
Notary Public . State of Attalla
MARICOPA COUNTY
My commission expires: My Commission June 16,2021 Explrea
(seal)
Warrant/Check Number
(if known) (6) 0022 55 if5 3c1
Original Date of Issue
(if known) (7) /13//olg
Reason for original issue of Warrant/Check (8): e=7
N/ Payroll rui
Lii For Services or Goods furnished APPROVED (n
111 Treasurer's refund/payment -n
Li Other:
Revised April 2015 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: " "Duplicate or It 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.
Chpay‘b ex *di (1), being first sworn, upon oath deposes and says:
Name1Claiman
On or about 5/ 2-/i_oit (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 q $ rir10 S6 .(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 skorn to before me this S day of 1).e.,c 2 0 .
NOTARY PUBLIC PORTIA hit LOMAX
NOtaly Public-State oi Aittona
My commission expires: My MARICOPA Commission COUNTY Explree
June16,2021 (seal)
Warrant/Check Number
(if known) (6) o022. 56 rl 14
Original Date of Issue
(if known) (7) 0.5/02 /zoiy?
Reason for original issue of Warrant/Check (8):
at/ Payroll
APPR ri
Eli For Services or Goods furnished C./
LI Treasurer's refund/payment
LI Other: CLERK, 00ArlD OF SUPERVISORS
MARICOPA COUNTY
Revised April 2015 A.R.S. 11-632 & 11-644