030817 DUPLICATE WARRANTS 8_REDACTED.PDF

Maricopa County
Human Resources
-7n10
L11 '0 Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: February 17, 2017
neiz, 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 Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant
Thank you.
Replacement Lost Warrant Form 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Iii 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.
Raymond Phillip Anderson (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 1.3/ issued to himAler in the st4 of $ 180.00 .(3)
Signed: ' „,*„70,c.. (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued
( ) ribed and sworn tefore me this { day of v.-(1 20 11 .
(
N-
NOTAR-Y-PUBLI
CINDY L. REINES
My commission expires: Notary MARICOPA Public - State COUNTY of Arizona
\ My Commission July 19, 2017 Expires (seal)
Warrant/Check Number 22439934
(if known) (6)
Original Date of Issue 11/30/2016 APPROVED
(if known) (7)
Reason for original issue of Warrant/Check (8):
IN Payroll CLERK, BOARD OF SUEl=1V- ISOPS
El For Services or Goods furnished m nn 1i7OPA CO U NTY
El Treasurer's refund/payment
El Other:
Revised April 2015 A.R.S. 11-632 & 11-644