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.:Pilaricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: October 19, 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 100D2102110ELEC10000 P21002 Dept: 2110 — Elections Stale Dated 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. Samantha Price (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 10/3/2018 (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 thitaim-As cqrrpct and the amount shown is due and owing, and the applicant requests tN, t' a reialacettriOnt r- --,--))- — -0, rn ....- warrant/check be issued to him/her An the sum of $ 712.12 41 / ril Signed: W ifiLlAitg tt /._ e c.i) .4. Note: Please attach a copy of the warrant/check if available and/or Ry other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this day of (.C.Ti•-(. 20 X. C (C) NOTARY PUBLIC COLLEEN M. REDMOND My commission /expires: Notary Public - State of Arizona Y -A )\ c Crirnisslon MARICOPA Expires COUNTY May 9, 2022 (seal) Warrant/Check Number (if known) (6) 22607493 10/3/2018 Reason for original issue of Warrant/Check (8): A hti ig Payroll El For Services or Goods furnished Cl ERVISORS ITv Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 81, 11-644