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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board . • -4 CA.) From: Lisa Platek eth 1A,alk4 de( vo Date: January 26, 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 Lisa at x 6-3619 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) / Duplicate Warrant Thank you. 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 I Instruction sheet which is page 2 of this form. Kristen Hoffmeyer (1), being first sworn, upon oath deposes and says: Name/Claimant On or about July 12, 2017 (date)(2) a warrant/check was issued to the above named person/entity in the amount as stated below. Such warrant/check was eitner never received or was sudsequenny inadvertently lost or destroyed ana tne 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 amount shown is due and owing, and the applicant requests that a replacement warrant/check be issued to him/her in the sum of $ 2821.64 , .(3) Signed: (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally Issue°. (5) Subscribed and sworn to before me this,_—; day of TecittAAz.,- 20 t . -NOTARY PUBL \i% DARCY ONCIAL ANN MACDERMID STAMP NOTARY PUBLIC-OREGON My commission expires: COMMISSION NO, 955028 MY COMMISSION EXPIRES OCTOBER 04,2020 (seal) Warrant/Check Number 22494346 (if known) (6) Original Date of Issue 07/12/2017 z).= (if known) (7) Reason for original issue of Warrant/Check (8): IA Payroll 0 For Services or Goods furnished -0 0 Treasurer's refund/payment Le? 0 0 Other: Revised April 2015 APP ED A.R.S. 11-632 & 11-644 JA 2 92018 DA ERK, BOARD OF SUPERVISORS MARICOPA COUNTY