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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: October 10, 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. ECEIVED Replacement Lost Warrant Form 1 6611152017 MARIDD7A COUNTY CLERK BOARD OF ,SUPERVISORS Cek Application for a Duplicate or Stale-Dated Warrant/Check Affidawilt/Cilaim Form This application is for: 1 Duplicate or I=1 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. Maria D. Lopez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 10/4/2017 (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 is o him/her in the sum of $ 991.84 .(3) Signed: (4) Note: Pleak 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 /041' day of OcUcr 20 /7 . NOTARY PUBLIC BERTA RAMIREZ My commission expires: Notary PAAR Public ICOPA - Stste COUNTY of Artz0411 Hay 1, 20/g My Commission Expires May?, 2018 (seal) Warrant/Check Number 225 PI LI-I (if known) (6) Original Date of Issue I o I 2-fl 2.017 AP1PROVED • (if known) (7) OCT DA Reason for original issue of Warrant/Check (8): Payroll CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY El For Services or Goods furnished III Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644