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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: April 16, 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 Li ida Greinke. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated V /arrant 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 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. Sherri L. Shepard (1), being first sworn, upon oath deposes and says: Name/CTdimant On or about April 4, 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* it as not presented for payment within one year after the date of issuance. : 77; :AD m Therefore, under penalty of perjury, claimant hereby affirms that this Ra clin' i?6orrea and the amount shown is due and owing, and the applicant requests thaC -aYeplacemeE2 warrant/cheds-4"issued to him tilhoe sum of $ 1,212.76 .(3)rn t -79 It-LA Signed: k,t _it (4).< 0- Notel-Pinse attach a -cupp 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 / day of 4 Fri- 1 20 1 NOTARY PUBLIC -arrtt. SUSAN D. SHEPARD Notary Public - State of Atizon. MARICOPA COUNTY My commission expires: " My Commission August 13, 2021 Expires vs al (seal) Warrant/Check Number 0022555289 (if known) (6) Original Date of Issue April 4, 2018 if known) (7 DAT Reason for original issue of Warrant/Check (8): Payroll CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY 111 For Services or Goods furnished El Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644 ,s-os--