011718 DUPLICATE WARRANTS 15.PDF

Maricopa County
Human Resources
Memo
Fran McCarroll, Clerk of the Board
From: Debbie Upton
Date: December 26, 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 Debbie U. at ext. 66329 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant
Thank you.
Replacement Lost Warrant Form 1 RECEIVED 02/25/2015
DEC 2 6 2017
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS u\oete&

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 2t'Duplicate or El 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.
/ez, (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about tk I I /at) 7 (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 $ 333.'7C .(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 at° day of beC 20 11 .
9,thm,115iltinw
NOTARY PUBLIC
EILEEN WILLIAMS-PREAS
Notary Public - State of Arizona
My commission expires: MARICOPA COUNTY
tt.°otg My November Commission 9, 2018 Expires (seal)
Warrant/Check Number
(if known) (6) aa5d.D6 > C=S
Original Date of Issue
(if known) (7) k\ L:9,017
Reason for original issue of Warrant/Check (8):
X Payroll _ m <
0 For Services or Goods furnished •••••I •• C:,
0 Treasurer's refund/payment Cr
0 Other: CLERK, MARIcopa BOARD OF rni SUPERVISORS )1VTY
C:\Users\williamse\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\HTTDL74G \Warrants Checks notice
of claim.doc
Revised April 2015 A.R.S. 11-632 & 11-644