091918 DUPLICATE WARRANTS 5.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Debra Upton
Date: August 17, 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 Debbie U. at ext. 66329 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
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: 0 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.
4atmar;*et, v-v-ii-D4,-Aq?"c9 (1), being first sworn, upon oath deposes and says:
Name/Claim nt t...,
On or about dia ba (date)(2) a warrant/check %4 ised gi the
above named person/entity in the amount as stated below. Such aranhecvas
either never received or was subsequently inadvertently lost or destr ,egd 5d tte is
no reasonable probability of its being found or presented for paym or It wVnot
presented for payment within one year after the date of issuance. c-,c) c:;) rn i
Therefore, under penalty of perjury, claimant hereby affirms that t ..clairizis corred
and the amount shown is due and owing, and the applicant requests that a Mlacement .
warrant/check be isalgtilo him/her in the sum of $ 3 50 .(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 swor to before me this 1114day of i--)AnTyl- 20 \ .
)-,/--y---
_
NOTAR UIJ BLIC
Crystal Santiago
• My commission expires: Maricopa Notary County, Publict Arizona
Ayl)CrEP,A. 115 My Comm. Expires 0245-2020 (seal)
Warrant/Check (if known) Number (6) 2 b 2. 5-E T?-72--
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
111 Payroll
El For Services or Goods furnished
El Treasurer's refund/payment
JX1 Other: Pri Coce5 to)ie .r9-s,eed
Revised April 2015