041217 DUPLICATE WARRANTS 1_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
' • s 7-3 tr* 0
From: Lind a Greinke
Date: March 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 Linda G./Lisa Platek at ext. 63770/63619 for any
questions. Please route approved Affidavits back to County
Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lot f Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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.
Stacey Faulkner (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 3/8/2017 (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/che le issued to him/her in the sum of $ 2040.76 .(3)
Signed: ---C-iCk-c_i2-/CAJL.J-L) (4)
Note: Ple4se f9 \ ttach a copy of the warrant/check if available and/or any other
evidence t t a / warrant/check was originally issued.
(5) Subscribed and sworn to before me this /3 day of MoL,r--C- k 20 1 7 .
4
NOTARY PUBLIC SUSAN D. SHEPARD
My commission expires: r(OrirRRr Prrilrirr Pitt rortliirr' -rIlr))111r
LA.,- / Pryy rornpur rcgir rioluo uI ' seal)
Warrant/Check Number 0022463607
(if known) (6)
Original Date of Issue 3/8/2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
El For Services or Goods furnished
El Treasurer's refund/payment
r_
LI Other:
Revised April 2015 A P A.R.S. 11-632 & 11-644
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CLERK BOARD OF SUPERVISORS
MARICOPA COUNTY