111616 DUPLICATE WARRANTS 4_REDACTED.PDF

30t.RD VIARICOP,4, OF SUPERYiSOWS CMUITI Maricopa County
Human Resources
2015 NOV -7 N 3:144
000 ck-
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: November 7, 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 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: • 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.
MARTHA SIGH (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09121/2016 (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 $ 140.00 .(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) Subscribed and sworn to before me this 315+- day of Cabi9e)f- 20(1) .
NO PUBLIC SHAMRA N. MARTINEZ
Notary Public - Arizona
Maricopa County
My commission expires: My Comm. Expires Mar 20, 2017
McLv.-11 2-011 Imr (seal)
Warrant/Check Number 22418711
(if known) (6)
Original Date of Issue 09/21/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
It Payroll
I=1 For Services or Goods furnished
El Treasurer's refund/payment
LI Other:
Revised April 2015 11-2 1f-9 !it 1.E., tC_1 A.R.S. 11-632 & 11-644
NOV18 2016
DAT,
CLERK, BOARD OF SUPERVISORS
MARICOPA COUNTY

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: CI 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.
MAYRA Y GONZALEZMADRID (1), being first sworn, upon oath deposes and says:
Name/Claimant
IN:)n 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 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 $ 155.00 .(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.
4, (5) S 1:5,1bed and sworn to before me this Ottill day of alpber 20
1\1(fitY PUBLIC
JUSTIN MARIE LARA
My commission.expires: NOTARY PUBUC STATE OF TEXAS
0 9(30430i 7 MY COMM. EXP. 9/30/17
NOTARY ID 129578644ea')
Warrant/Check Number ItsamemiatiMINOMOIRRINIXIIPRIMIN
22417656
(if known) (6)
Original Date of Issue 09/21/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
For Services or Goods furnished
CI Treasurer's refund/payment
II Other:
Revised April 2015 A.R.S. 11-632 & 11-644
RK, 'BO D • OF SUPERVISORS
MARICOPA COUNTY