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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: October 31, 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 Zellnor. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. RECEIVED NOV 01 2017 Replacement Lost Warrant Form MARIcopAWORA, CLERK BOARD OF SUPERVISORS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. Baltazar Hernandez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 6/28/17 (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 $ $529.22 .(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 7j! day of 20 / . NOTARY PUBLIC' My commission expires: 17, (seal) Warrant/Check Number 22491001 (if known) (6) Original Date of Issue 6/28/2017 Cif known) (7) Reason for original issue of Warrant/Check (8): • Payroll O For Services or Goods furnished O Treasurer's refund/payment O Other: Revised April 2015 A.R.S. 11-632 & 11-614 AP NO DAT rn RK, BOARD OF SUPERVISORS MARICOPA COUNTY .MI=MA rn •• Crt