091918 DUPLICATE WARRANTS 6.PDF

Maricopa County
Human Resources
Memo
11-4x Fran McCarroll, Clerk of the Board
From: Zellnor Bullis
Date: August 22, 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.
Dept 5520 Account/Fund: 100D5505520REC01000 P55010
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 El 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.
dte being first sworn, upon oath deposes and says:
,
On or about GO/ 20 I (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 is-corrftt
and the amount shown is due and owing, and the applicant requests th 1-- c- epiffeemen , rn
c--- ...... -a -pp ...... , IF - •
warrant/check be issued to him/her in the sum of $ 73-1 9 1 Ci '70
rc'-',o Tx rn
, ..„
Signed: 1j06/01 , /44_
—4 ul
Note: Please attach a copy of the warrant/check if available an or anfroother
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this 13 day of 4ivribt- 20 15 .
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NOTARY
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My commission expires: ." .-- ri1 M ;''
.00 /3 ,Ari 0 4/80c
0 I-1i Zir2,0 (seal)
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Warrant/Check Number
(if known) (6)
Original Date of Issue PPRO'VED
(if known) (7) /13 I
DA
Reason for original issue of Warrant/Check (8):
Payroll CLERK. BOAF-'75-5F7VII J. ,-
MARiCCPA :;OUNT"‘"
O For Services or Goods furnished
O Treasurer's refund/payment
O Other:
Revised April 2015 A.R.S. 11-632 & 11-644