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606A SO \ RD OF SLIP Maricopa County : 1 Human Resources 2011 Jit 19 11ii 19: 5 1 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Milliron Date: July 19,2017 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 M. at ext. 62406 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 JZ1 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. tr-_--p to LA.---DFoKLD (1), being first sworn, upon oath deposes and says: Name/Claimant On or about i //--)/2-0 (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, a 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 hi /her in the sum of $ i -r;Z; ° .(3) C:\,, Signed: , (4) Note: Please attach '5 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 th I day of 20 1 7. Raymui id Su garlic NOTARY PUBLIC Notary Public Maricopa County, Arizona My commission expires: My Comm. Expires 2-9-2020 -2-d7_0 (seal) Warrant/Check Number f:90 2,-2-i-1 7 3 (if known) (6) Original Date of Issue /?,7o /Z0 i. (if known) (7) Reasop for original issue of Warrant/Check (8): V Payroll A PPROVED 0 For Services or Goods furnished • . LI Treasurer's refund/payment 1111P4P1111,17 , CARD° asffir: 4 0 Other: mAQ1CO'A auuni Y Sop C:\Users\williamse\AppData \Local \MicrosoftWindows\Temporary Internet Files \Content.Outlook\HTTOL74G\Warrants Checks notice of claim.doc Revised April 2015 A.R.S. 11-632 & 11-644