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Maricopa County Human Resources RECEIVED Memo SEP 1 4 2017 CLERK MARICOPA BOARD OF COUNTY SUPERVISORS To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: September 14, 2017 Re: Replacement of Lost Payroll Warrants Please find attached I 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 Lisa P. at ext. 63619 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 121/Duplicate or 1=1 Stale-Dated (definitions are on page 2) STATE OF ARIZONA II on this Coyrr-ii correspond to numbers on th e COUNTY OF MARICOPA Instruction sheet 1111 is page 2 of this Hrrr IQVA-eS fkciv-ce ‘-- a (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 1-‘2--V1 (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 $ I 41 (0, Z. 0 .(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 I L4 ectiunk_axikciinv NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Public - State ot Arizona MARICOPA COUNT( My Commission Expires November 9, 201e Warrant/Check Number 2. 2 Li- go-1-4- 3s (if known) (6) 1-1 2 -t1 Reason for original issue of Warrant/Check (8): CLIRK, BOARD OF SUPERVISORS MARICOPA COUNTY El For Services or Goods furnished El Treasurer's refund/payment El Other: S: \Payroll_Records\Payroll \Processing_Guides\Department\Affidavit for Warrants Checks notice of claim.doc Revised April 2015 A.R.S. 11-632 & 11-644