011117 DUPLICATE WARRANTS 10_REDACTED.PDF

HARICCP:‘ OF , IF Maricopa County
Human Resources
2rd OF_C, 29 2: ti,9
HV CL,
Memo
To: Fran McCarroll, Clerk of the Board
From: Lisa Platek
Date: December 27, 2016
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 Lisa at x 6-3619 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant (Over I Yea Duplicate Warrant
Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 10 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.
Jose L Rojas Parra (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 12/14/2016 (clate)(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 him/her in the sum of $ 942.26 .(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 27 day of b-e- C 20 I(.
gawk-LOW:um° PkuctA
-
NOTARY PUBLIC
EILEEN WILLIAMS-PREAS
My commission expires: Notary Public • State c..JouNrr of AttOba
1 (.L1 2O lLi MY WtRICOPA Commission 2018 Expires (seal)
November
Warrant/Check Number 22444858
(if known) (6)
Original Date of Issue 12/14/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
• For Services or Goods furnished .CLERK, MARICOrA BOARD OF COP SUPERVISC
El Treasurer's refund/payment
El Other:
Revised April 2015 A.R.S. 11-632 & 11-644