022118 STALE DATED WARRANTS 1.PDF

Maricopa County
Human Resources
RECEIVED
Memo JAR 3 0 2018
MARICOPA -CUNTY
CLERK BOARD OF SUPERVISORS
To: Fran McCarroll, Clerk of the Board
From: Zellnor Bullis
Date: January 30, 2018
Re: Replacement of Lost Payroll Warrants
Please find attached I 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.
Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
tA 3:1-111
This application is for: uplicate or ,Stale -Dated (definitions are on page 2)
STATE OF ARIZONA PiU , r'Note: Numbers on this form'correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
„.....--
JC55S-CA "IAN (1), being first sworn, upon oath deposes and says:
Name/G aimant
On or about 11130/Z011P (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 issued to him/her in the sum of $ 41t I 14 9(• .(3)
Signed: (4)
Note: Pleage/eitach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscrib and sworn to before me this 021.2 day of -1-1-a-4n— 20 ig/ .
NOTARY PUBLIC
OFFICIAL SEAL
VICKI R. CHAVARRIA
My commission expires: Notary Pitlic State of Arizona
/-3/ - My MARICOPA Comm Expires COUNTY Jan. 31,2019 (seal)
Warrant/Check Number oorzA Scl8S8
(if known) (6)
Original Date of Issue 1110/21)1(0
(if known) (7)
Reasop- for original issue of Warrant/Check (8):
Ef Payroll
El For Services or Goods furnished
LI Treasurer's refund/payment
El Other:
Revised April 2015