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Maricopa County Human Resources Memo 7 1-1 cP To: Fran McCarroll, Clerk of the Board From: Debra Upton Date: July 30, 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 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 1.7:1 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. Tre,vc( Doms (1), being first sworn, upon oath deposes and says: Name/Claimant On or about M 2-5) 10 1 (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 amountg de hown is due a c1-1,vvinil-- d the applicant requests that a replacement warrant/che AO ;to, merin tfjesurn-Thf----- .__ cmo. 5)---/ .(3) Signed: _ (4) • I _ Note: Please attach a copy of the warratWeffe-ck if available and/or any other evidence that a warrant/check was originally issued (5) Subscribed and sworn to before me this 3c)- * day of 20 \ % . c\c--\ c_ NOTARY PUBLIC MARIA C SALAIZ Notary Public, State of Afizona Marioopa County My commission expires: My Commission Expires Febtuar 2, 2021 (seal) Warrant/Check Number p 2. 2-58(245S? (if known) (6) Original Date of Issue I/261 2-0 t (if known) (7) Reasop4r original issue of Warrant/Check (8): e' Payroll LI For Services or Goods furnished D Treasurer's refund/payment 111 Other: Revised April 2015 A.R,S, 11-632 & 11-644