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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board __; From: Lisa Platek , nate: December 29, 2017 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: E 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. Tessa Hustead (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/13/2017 (clate)(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 $ 1565.00 , .(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. (5) Subscribed and sworn to before me this ZCt day of D;C_Okk.k0e.1.- 20 Cl . N( 6)11 TTAA'RR -4kPul PPIUUBBLLEIT C;)-1-14"41 .z..54 TIFFANY PARKERSON My commission expires: ) Notary Public - State of Arizona My MARICOPA Commission COUNTY Expires (seal) Warrant/Check Number 22530364 (if known) (6) Original Date of Issue 12/13/2017 (if known) (7) APPROVED Reason for original issue of Warrant/Check (8): • Payroll K. BOARD OF SUPERVISORS 111 For Services or Goods furnished MARICOPA COUNTY 111 Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644