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CLERK BOARD MARICOPA OF SUPER COUNTY VISOR'S Maricopa County Human Resources 2018 MAY -9 PM 01 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Milliron Date: May 9, 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 M. at ext. 62406 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form z This application is for: LeDuplicate or 0 Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the C UNTY OF MARICOPA Instruction sheet which is page 2 of this form. (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 1\41\-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 destroyOlndatherer# no reasonable probability of its being found or presented for payment,* it ps presented for payment within one year after the date of issuance. ma- c-, Therefore, under penalty of perjury, claimant hereby affirms that this c4Ziii) is- 12orreet. and the amount shown is due and owing, and the applicant requests thatW2pla'eme N) warrant/check be issued to him/her in the sum of $ o . 0.1(3) Cr, 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 sworn to before me this e day of 20 18 . "1\16tAWP6BLIC ELIZABETH S. VALENZUELA My commission expires: Nc‘sy MARICOPACOUNTY POD- State of A403na CC-iv/vet - 2 , 2 cl My October Oommission 29, 2019 Expires (seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): '51 Payroll LI For Services or Goods furnished CLERK, 8 ARD OF ELL'EnVISCRS MARICCWA COt INTv 0 Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-644