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5 flARICOPACUHi A D.. OF iii -1 Maricopa County 1018 OCT 31 PH 2: 54 Human Resources 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: 100D2102120ELEC1000 P21047 Dept: 2120— Election Cycle 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 111 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. Randall Scott Holmes (1), being first sworn, upon oath deposes and sa ys: Name/Claimant On or about September 19, 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 subse quently inadvertently lost or destroyed and there is no reasonable probability of its bein g found or presented for pa yment, or it was not presented for pa yment within one year after the date of issuance. --r Therefore, under penalty of perjury, claimant hereby affirms that this cr4. iscorre??1 and the amount shown is due and owin g, and the applicant re quests that Kr,gpla cAmerit, v— C3 k warrant/check be issued to him/her in the sum of $ 195.50 m Signed: (4)?ar- z, Note: Please attach a copy of the warrant/check if available and/e any ather evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this 0 day of d LAD\e-v 20 . -0) NO ARY PUBLIC loinarobwirlibialx.Wmaxiabiox JESSICA ALVAREZ 0 Notary Public - Arizona My commission expires: :1k::_ ,. e%1:j), • Commission Maricopa Count #551543 y •i my Comm. Expires Sep 13, 2022 0 (seal) a Warrant/Check Number (if known) (6) 22604035 Original Date of Issue (if known) (7) September 19, 2018 Reason for original issue of Warrant/Check (8): Payroll APPROVED 0 For Services or Goods furnished ETreasurer's refund/pa yment Hl 8UAHO VP- bUHViSORS Other: Revised April 2015 A.R.S. 11-632 & 11-644