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[3{)/" D OF J SJf'"~·.' ' I ' ,S<;;, ·s Maricopa County
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Human Resources
2017 JUL 2t~ P l 2: OS
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: July 24, 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.
Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 02/25/2015
r Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/ Claim Form
This application is for: D Duplicate or D 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.
~b tf! t~ (1), being first sworn, upon oath deposes and says:
ame/Cia1mant 3 N c1V- ;;,_ 0 / b
On or about if ~ :Z d/ 'T (date)(2) a warrant/check was issued to the
above named pers ~ity 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$ /.50. ........... /J~ ----.(3)
Signed: ~1d-v y? J}~o.A_ (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 (q~ day of <-_\~ 20_H_.
~
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My commir ion expires: ~~~.J ~~ MrComm. Mal1oopa County, &plrD$ Artt!lne tJ.tJ.tl
11..{1-=t- \~ 0 ,.._, = (seal)
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Warrant/Check Number 22440556 ~ ' ' ~: ' r c_ (_- - [Ul ()
(if known) (6) I - ' •' ) 'J l ~ l
Original Date of Issue 0
/ (if known) (7) 11/30/2016 ~. ,c:: .. ~
r~ ' _.,~ J : -- y
Reason for original issue of Warrant/Check (8): r -:
0 Payroll U)-~
0 For Services or Goods furnished _________ -t __ A_P_P----=R=· 0 V E
o Treasurer's refund/payment -----------+---=:.;zr.=r===~~~.=.....:-n
N Other: a>;}- h rJ ern_
Revised April 2015 A.R.S. 11-632 & 11-644