Extracted text (via pymupdf_layout)
2357 characters
Maricopa County Human Resources Cil =73 Memo -^ To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: November 14, 2017 Re: Repacement of Lost Payroll Warrants Please find at:ached 1 Affidavit/Notice of Claim(s) for lost payroll warrarts 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 c riginal warrant(s) have had a stop payment done. Please call Linda Greinke. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Los I Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: [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. N'l -124AA itc)stcmaik (1), being first sworn, upon oath deposes and says: Name/Ct mant On or about 71- (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 $ 1 2_9 (..k 9 43) Signed: - / -'1 / (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) Subscr.A . ed anp. sworn to before me this Hthday of 1\f (nKri2 f, It 2011. NOTARY P BLIC Ihrt,,Icr3r /rel My _commission expires: .fttnecopi CC 1)\--0,1\ Ti t o154 ; My Lamm. -.:;;pre3 -1"/ 18 (seal) Warrant/Check Number 00-12-5 20 1- Cs2 (s) (if known) (6) Original Date of Issue 11 /0\17.01 -1- (If known) (7) Reason for original issue of Warrant/Check (8): Payroll El For Services or Goods furnished Lii Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644