022118 DUPLICATE WARRANTS 11.PDF

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Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: February 5, 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 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: Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
UNTY OF 1\yIRICOPA Instruction sheet which is page 2 of this form.
(1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about (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 amount shown is due and owing, and the applicant requests that a replacement
warrant/check be issved to hiAler Athe sum of $ ''4171 .(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 issued. .70 rI-$
-<x7.
(5) Subscribed and sworn to before me this 5 day of faiR/-7 er, -,204
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NOTARY PUBLIC
PORTIA M. LOMAX
Notary Public- State of Arizona er Th.. 0
My commission expires: My MARICOPA Commission COUNTY Expires
June 15, 2021 z- (seal)
Warrant/Check Number
(if known) (6 3 i)
Original Date of Issue ti'zglsolb
if known) (7
APPROVED
Reason for original issue of Warrant/Check (8):
,K Payroll FEt3)0 5 201
O For Services or Goods furnished
L.LEHK, BOARD OF SUPERVISORS
O Treasurer's refund/payment MARICOPA COUNTY
El Other:
Revised April 2015 A.R.S. 11-632 & 11-644