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Maricopa County Human Resources grN.M CZ) Memo ril (DJ rs..) To: Fran McCarroll, Clerk of the Board From: Zellnor K Bullis itaij lelivtred Date: February 28, 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 Zellnor B. at ext. 60409 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: El Duplicate or 14Stale-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. rno\N Q...econ (1), being first sworn, upon oath deposes and says: Na e/Claimant On or about MCA're 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. 752 , e-' 452 7:1 Therefore, under penalty of perjury, claimant hereby affirms that thisjiiim t!gcorrat and the amount shown is due and owing, and the applicant requests th4t2geAcem warrant/check be issued to him/her inite sum of $ T,.93-cic) > .(03Y4 Y‹ Signed: (61-74 cf, th., Note: Please a ach a copy of the warrant/check if available and/or an cyn other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this IF day of 1•1 ,04 20 1 NOTARY PUBLIC di D Cirifsivs Notary Public - Arisons My commissipp expires: Maricope County tikc 2N 20R- My Commission bar points (seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): X Payroll CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY El For Services or Goods furnished El Treasurer's refund/payment 111 Other: Revised April 2015