062117 DUPLICATE WARRANT - 5.PDF

mt eeenes iVaricopa County
”
He Human Resources
cs
Vemo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: June6, 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 U. at ext. 6-6329 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
—
Stale Dated Warrant .
Warrant »\
( cP
ws es
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

phy 22
Application for a Duplicate or Stale-Dated Warrant/ Check
h es |) |
ear
Affidavit/Claim yo . Form Couns.
This application is for: D4] Duplicate or C] 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.
“Bonn V2. Zamarvo Y\___(1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about Moy 31. ZO — (date)(2) a warrant/check was issued to the
above named person/ehtity 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 $ g Lbe.aAaeD (3)
Signed: 2. J) (4)
Ee attach
Note. 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 lo day of a) WALL 20\"{.
Cow Wut ~As wg
NOTARY PUBLIC
EMEEN WILLIAMG-PREAS
im,
My commission expires: : SEC PRGGUNTY
WO 201’ My Cormiesion Expires | (seal)
-
Warrant/Check Number
QOUSL AR 172)
(if known) (6)
Original Date of Issue
S ‘S\ 2 V1 =p
(if known) (7) a ;
Reason for original issue of Warrant/Check (8):
Sx Payroll
C1 For Services or Goods furnished
(1 Treasurer’s refund/payment
LJ Other:
Revised April 2015 A.R.S. 11-632 & 11-644