072617 DUPLICATE WARRANTS 11.PDF

BOARD OF CLERK SUPER VISOR Maricopa County
MARICOPA rOUNTY Human Resources
2017 JUL 1 4 PH 2: 08
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: July 13, 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 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 0 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.
Lilyanne McKennah Legan (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/30/2016 (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 reasonabIe 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 $ 140.00 .(3)
Signed: 30(\ (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
,Subscribed and sworn to before me this 9-7411 day of ..S.L.L.),
Warrant/Check Number 22438438
(if known) (6)
Original Date of Issue 11/30/2016 •
(if known) (7)
Reason for original issue of Warrant/Check ( N)
Payroll APPROVED
-70
LI For Services or Goods furnished DATEA 1 I••••• • •
-ThritAirr rrtLiillrr
MARICOPA COUNTY
111 Other:
A.R.S. 11-632 & 11-644