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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: November 13, 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 (Over 1 Year) Thank you. ct, Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. )61\-g-jrnant a46 (1), being first sworn, upon oath deposes and says: On or about II \ t ..ovi. (date)(2) a warrant/check was issued to the above named person/ ntity 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 paymer4 or it.,,was not presented for payment within one year after the date of issuance. f.7‹, ---." X-,- , _ — 6-_-.: --,,-,.;-0 = --) rn Therefore, under penalty of perjury, claimant hereby affirms that this---Nim -S corroct and the amount shown is due and owing, and the applicant requests tl-ii-0 ..,-0 retipcerfilliit ........ m c`) warrant/check be to him her in the sum of $ S-3 e). 9(4 (1301 E . r" C.) Signed; J4) 0- 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 day of 20 NOTARYAMBLIC JO ANN R. LE'YVA Notary Public- State of Arizona My commission expires: MARICOPA COUNTY My Commission Expin3s (seal) October 24, 2019 Warrant/Check Number (if known) (6) 155r1 Original Date of Issue (if known) (7) 1011 Reason for original issue of Warrant/Check (8): Payroll CLERK, BOARD OF SUPERVISORS fl For Services or Goods furnished MARICOPA COUNTY 111 Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644