110216 DUPLICATE WARRANTS 1_REDACTED.PDF

Maricopa County
Human Resources
Memo
Wow.' Fran McCarroll, Clerk of the Board
F[rom Wanda Childers
Ba'`be October 13, 2016
Reri] 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: • 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.
SHEILA R KARTSONAS (1), being first sworn, upon oath deposes and says:
Narne/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 correct
and the amount shown is due and owing, and the applicant requests that a replacement
warranticlifecK ,be issued to him/her in the sum of $ 140.00 .(3)
Signed: ("760 n/od)- (4)
Note: Plea attach a copy of the warrant/check if available and/or any other
evidence at a warrant/check was originally issued.
(5) Subscribed and sworn to before me this .--7 . L 1, \ day of (,) Qt...01w I— 20
.-,Ao,-.-cs2A) cx,y\atrv,D
NOTARY PUBLIC
FRANCES HANSON
My commission expires: Notary Public. State of Arizona
,2 () 79 my Commission MARICOPA xOres COUNTY Feb. 21, 2118 I (seal)
Warrant/Check Number
(if known) (6) ;1'M// 7?'/
Original Date of Issue 09/11/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
▪ Payroll
LI For Services or Goods furnished
0 Treasurer's refund/payment
D Other:
Revised April 2015 A.R.S. 1-1-632 & 11-644