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Maricopa County Human Resources rap Clo Memo CFI To: Fran McCarroll, Clerk of the Board ce? From: Zellnor Bullis Date: November 6, 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-Elections 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: l 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. Ronald Downham (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 him/her in the sum of $ 247.25 .(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 syv%-n to before me this NOTARY PUBLIC MICHAEL DEAN MILLER Notary Public - Arizona My commission expires: Maricopa CounV 7 - ( Commission #1134079 eal) Commission Expires August 27, 20011, cxo Warrant/Check Number (if known) (6) 22603893 Original Date of Issue (if known) (7) September 19th, 2018 11.1.40. Reason for original issue of Warrant/Check (8): <fi ••II• 0 • Payroll (.14 ID For Services or Goods furnished AP PROVED I OTreasurer's refund/payment DATIr Other: 773Wrstltralo Ri MARICOPA COUNTY Revised April 2015 A.R.S. 11-632 & 11-694