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Maricopa County Human Resources 2f;i11-)EC Memo Tog Fran McCarroll, Clerk of the Board From: Linda Greinke Date: December 12, 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 Linda at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warra -r-i-t) Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form -wimp This application is for:N f/ 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. VVIOC\ Scokt (1), being first sworn, upon oath deposes and says: ame c ailment On or about niP.Mbei NI 2o17 (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 him/her , in the sum of $ 55 'e bq .(3) Signed: . s (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 Eday i€- of 0-'a c----(-"cc 20 eret.„.x,S_ NOTARY PUBLIC My commission expires: 13/ (00 2Zrj, (seal) Warrant/Check Number "2-n (if known) (6) 00225 Original Date of Issue I 2q D (if known) (7) Reaspn for original issue of Warrant/Check (8): CLERK, BOARD OF SUPERVISORS it Payroll MARICOPA COUNTY 0 For Services or Goods furnished 0 Treasurer's refund/payment Li Other: Revised April 2015 A.R.S. 11-632 & 11-644