120716 DUPLICATE WARRANTS 6_REDACTED.PDF

Maricopa County
Human Resources
Me
To: Fran McCarroll, Clerk of the Board
From: Linda Greinke
Date: Nov,.mber 17, 2016
Re: Replacement of Lost Payroll Warrants
Please find aitached I 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. at ext. 63770 for any questions. Please route
approved Affi lavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lo: Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
•
This application is for: Duplicate or D 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.
Duanne Wilster (1), being first sworn, upon oath deposes and says:
nnenairn ant
On or about 11/02/2016 (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 be issued to him/her in the sum of $ 1304.21 .(3)
Signed: L1cA )cUld-d (4)
Note: Please attach a copy of the warrant/check- if available and/or any other
evidence that a warrant/check was originally issued.
ancl sworn to before me this J (.1-, day of AbLMIle,20
PEGGY BUTCHER
My commission expires: Notary MARICOPACOUNIY Pubire • %Is 4a
_EA ct My Commission January 2,2019 Expimos .J1
Warrant/Check Number 2430860
(if known) (6) 1
Original Date of Issue 11/02/2016
(if known) (7)
Reason for original issue of Warrant/Check (8): FE:)1' 1`9
IR Payroll APPROVE _ 1J
CI For Services or Goods furnished NO4k17 /01t
El Treasurer's refund/payment
LI Other:
Revised April 2015 A.R.S. 11-632 & 11-644