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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: January 17, 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 Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: IYDuplicate 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. Edward Winfield (1), being first sworn, upon oath deposes and says: Name/Claimant On or about Olit0/2018 (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/chec issued o him/her in the sum of $ / 77 , W .( 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 1 —7 day of si eLn 20 l . NOTARY RY PUBLIC EILEENWIECRWPM-S My commission expires: Notary Public - State of Arizona My MARICOPA Commission COUNTY Expires (seal) November 9, 2018 Warrant/Check Number 22536287 (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): Payroll El For Services or Goods furnished RK, MARICOPA BOARD OF cot SUPERVISORS INTY 0 Treasurer's refund/payment 111 Other: Revised April 2015 A.R.S. 11-632 & 11-644 COL _12)-L0A_G.....- pC-c-k-uy