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Maricopa County Human Resources Memo XS' CfN -- To: Fran McCarroll, Clerk of the Board - From: Linda Greinke Co c_n Date: August 16, 2017 Re: Replacement of Lost Payroll Warrants Please find attached 1 AffidaviuNotice 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 Linda G.. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate 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: 0 Duplicate or 0 Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the /1 COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. (1), being first sworn, upon oath deposes and says: Nameicruimaiii INIC1111C/lAt1111101 It Rap On or about 0 7- / /c2/(90 (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/c fêcI be issued to 1"Øm/her i urn of $ q09`0'S .(3) (1 If (-7' I i A 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) Subscrib d- worn to before me this 12-16 day of Aocis+ 20 17. NOTARY4'UBLIC JUSTIN MARTIN Notary Public - State of Arizona My commission expires: My MARICOPA Commission COUNTY Expires 02/ 00/0a 2-) February 8, 2020 (seal) Warrant/Check Number (if known) (6) Original Date of Issue o ot 1- (if known) (7) ) 61 Reason. for original issue of Warrant/Check (8): ig Payroll O For Services or Goods furnished O Treasurer's refund/payment O Other: Revised April 2015 A.R.S. 11-632 & 11-644 CLERK, BOAFiD OF SUPERVISORS MARICOPA COUNTY