011619 DUPLICATE WARRANTS 15.PDF

Maricopa County
Human Resources
Memo
Ui CA)
To: Fran McCarroll, Clerk of the Board
From: Zellnor Bullis
Date: December 18, 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 Zellnor B. at ext. 60409 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 11 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.
Susan Neile Prescott (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, 91 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 $ 352.26 .(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) Subscrib d sworn to before me this \ -7 It day of )eaAIL)7,i,- 20 I .
d-1 -
N-t•TA Y PUBLIC sillraremshahNi61/
LUIS GARCIA
My commi qr wires: Notary Maricopa Public County -Arizona
n -7 , z 2 Commission # 550346 (seal)
My Comm. Expires Jul 6, 2022
Warrant/Check Number
(if known) (6) 22619493
Original Date of Issue
(If known) (7) 11/28/2018
Reason for original issue of Warrant/Check (8):
fl Payroll
EO For Services or Goods furnished
GI Treasurer's refund/payment
E I Other:
Revised April 2015 A.R.S. 11-632 & 11-644