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Maricopa County Human Resources Memo C• To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: November 17, 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 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. Madison Bohan (1), being first sworn, upon oath deposes and says: Name/Claimant On or about July 16, 2017 (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 $ 729.68 .(3) Signed: 41/Led/II (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 1 day of 004 NOTARY PUBLIC My commission expires: Notary Public - State of Arizona MARICOPA COUNTY 11.q-20141 My Commission Expires (seal) November 9, 2018 Warrant/Check Number 0022497923 if known) (6 Original Date of Issue 7/26/2017 (if known) (7) 1-1 Reason for original issue of Warrant/Check (8): _ Payroll ERK, BOARD OF SUPERVISL—n- MARICOPA COUNTY For Services or Goods furnished El Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644