011619 DUPLICATE WARRANTS 19.PDF

Maricopa County
\\04\ Human Resources
2011 DEC 214 ttli 9: 32 Oev--
Memo
To: Fran McCarroll, Clerk of the Board
From: Monica Reyes
Date: December 24, 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 Monica at x 6-8051 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant (Oveir Year)
Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate 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.
Kenneth Hicks (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about December 12, 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 issu to him/her in the sum of $1,516.74 .(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 2 i day of De c- 20i .
aellip,0-1(-
NOTARY PUBLIC EILEEN WILLIAMS-PREAS
Notary Public • State of Arizona
SAARICOPA COUNTY
My commission expires: Expires Commission November 0 654349 9, 2022
II - 61-202,2 (seal)
Warrant/Check Number 0022624247
(if known) (6)
Original Date of Issue December 12, 2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
0 For Services or Goods furnished C_ERK, BOARD OF SUPERVISORS
MAFIICOPA COUNTY
ID Treasurer's refund/payment
0 Other:
Revised April 2015 A.R.S. 11-632 & 11-644