011117 DUPLICATE WARRANTS 3_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: December 13, 2016 C.0 CD
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 Wanda at ext. 60409 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 Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for g Duplicate or U Stale-Dated (definitions are on page 2)
STATE OF ARIZONA T Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Valentin Obregon (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/30/2016 (date)(2) a warrant/check was issue tos;the
above named person/entity in the amount as stated below. Such warrant/clieckiltas
either never received or was subsequently inadvertently lost or destroyed and:theFe is
no reasonable probability of its being found or presented for payment / or it was:iinot
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim 1.coli fect
and the amount shown is due and owing, and the applicant requests that a repgThenrgra
warrantichecik by-iss99d to 11n/her er in the sum of $ .(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 lcV.J7,--tay of AaLdzi egi20,7re, .
t1J E7 7) e-e—keL/—f
NOTARY PUBLIC
GLORIAJ. NICHOLS
Notary Public-State ofArizora
MARICOPA COUNTY
My Commission Expires Feb. 23, 2014 (seal)
Warrant/Check Number 2243888 6
(if known) (6)
Original Date of Issue 11/30/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
lil Payroll
Li For Services or Goods furnished
1=1 Treasurer's refund/payment
LI Other:
Revised April 2015 A.R.S. 11-632 & 11-644