062117 DUPLICATE WARRANT - 2.PDF

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BOARD RICOP OF SUPEE YISOR'S Maricopa County
2017 HAY 31 PH 1: 34 Human Resources
Memo
To: Fran McCarron, Clerk of the Board
From: Debbie Milliron
Date: May 31, 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 Stak -Dated Warrant/Check
Affidavit/Claim Form
This application is for: g 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.
Margaret L Sampley (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 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 $ 125.00 .(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 day of C.AG.Li 20 (-) .
NOTARY PU
My comrv)issli 'expires:
91 l lo -2_ (seal)
Warrant/Check Number 22439286
(if known) (6)
Original Date of Issue 11/30/2016
(if known) (7) ••I••••••
Reason for original issue of Warrant/Check (8): •••••
II Payroll
LI For Services or Goods furnished
LII Treasurer's refund/payment (.7?
0') - • - 4—
El Other:
Revised April 2015 E D A.R.S. 11-632 & 11-644
JUN 02 2017
CLERK. 30AF-1D OF SUPERVISORS
MARICOPA COUNTY