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D I OF COI" SLIP; A 1 Maricopa County Human Resources /018 OCT 31 PH 2: 53 Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: October 31, 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 Zell B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Acct/Fund: 10002102120ELEC1000 P21047 Dept: 2120— Election Cycle 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: NI Duplicate or 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. Terry Loma (1), being first sworn, upon oath deposes and says: Name/Claimant On or about September 19th, 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 issued to him/her in the sum of $ 278.38 .(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. n to before me this `-- day of 20_ S/. HOPE M. OLGUIN Notary Public - State of Arizona 1 MAR ICOPA COUNTY (seal) My Commission Expires April 4, 2022 Warrant/Check Number (if known) (6) 22602943 Original Date of Issue (if known) (7) September 19th, 2018 Reason for original issue of Warrant/Check (8): n 0 Payroll O For Services or Goods furnished _ JailiviAtu O Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-614