011117 DUPLICATE WARRANTS 11_REDACTED.PDF

CLEk:,
BOARD FIAP,r.0 OF FtJT 7' Maricopa County
21i5 DEC 29 iJ Human Resources
M 0 r_O ..11;
To: Fran McCarroll, Clerk of the Board
)
From: Wanda Childers
171a. e: December 29, 2016
Re: Replacement of Lost Payroll Warrants
Please find attached 2 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 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: g 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.
PHYLLIS D LEWIS (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09/11/2016 (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 corrqct
and the amount shown s due and owing, and the applicant requests that a replacement
warrant/check be issued to him/her in the sum of $140.00 .(3)
(7) CD
Signed: 41.04.zt (4) I
, "")
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that,a warrant/check was originally issued.
(5) Subscyi,ed and svyorn to bef re me this day of 20\ .
_blerrAkY PUBLIC LINDA HALE-HASAN
Wary Public - Siete of Arlzboa
My ciorpfriission expires: My MARICOPA Commission COUNTY Expires
December 21). 2018 (seal)
Warrant/Check Number 22418061
(if known) (6)
Original Date of Issue 0912J/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
El For Services or Goods furnished
Li Treasurer's refund/payment
111 Other:
Revised April 2015 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/ Claim Form
This application is for: g 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.
JOHN CLARK LOCHER (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09/21/2016 (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check:Vvas
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 vvaS T:\pot
presented for payment within one year after the date of issuance.
CD
Therefore, under penalty of perjury, claimant hereby affirms that this ct
and the amount shown is due and owing, and the applicant requests that a reRtaceent
c.r)
warrant/check be issugto him/her in the sum of $ 165.00 .(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) Subscrjbed Ad sworn to before me this 711' day of D'E 20/(i2.
OTARY—PUBLIC YPlJti
Si V V- 11F ARP' t p ,IA
'
nrinIsp,rs: KATIL-1 EA4A11
,vly AtiU116,il I , (seal)
i Warrant/Check Number 22419963
(if known) (6)
Original Date of Issue 09/21/2016
(if known) (7) A id be' riLd kId
Reason for original issue of Warrant/Check (8):
111 Payroll
LII For Services or Goods furnished
CI Treasurer's refund/payment
Other:
Revised April 2015 A.R.S. 11 -632 & 11-644