110216 DUPLICATE WARRANTS 5_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
kn .
From: Debbie Upton
Date: October 19, 2016
Re: Replacement of Lost Payroll Warrants
Please find attached *3 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 Debbie U. at ext. 66329 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
is for: gl Duplicate or El Stale-Dated (definitions are on page 2)
This application
Note: Numbers on this form correspond to numbers on the
STATE OF ARIZONA Instruction sheet which is page 2 of this form.
COUNTY OF MARICOPA
JOEL JEFFREY LIPSMAN (1), being first sworn, upon oath deposes and says:
Name/Claimant 09/p /2016 (date) (2) a warrant/check was issued to the
On or about person/entity in the amount as stated below. Such warrant/check was
above named subsequently inadvertently lost or destroyed and there is
either never received or was found or presented for payment, or it was not
no reasonable probability of its being
presented for payment within one year after the date of issuance.
penalty of perjury, claimant hereby affirms that this claim is correct
Therefore, under shown is due and owing, and the applicant requests that a replacement
and the amount
warrant/check be issued to him/her in the sum of $ 165.00 .( 3 )
(4)
Signed:
Please {attkh a copy of the warrant/check if available and/or any other
Note: evidence that a warrant/check was originally issued.
and sworn to before me this /// day of 2 I 20]
(5) Subscribqd
Notary SHARON Public MONTER - Arizona
NOTARY PUBLIC Malcolm County
My Commission Expires
March 14, 2017 ar
My commission expires: ramme (seal)
Warrant/Check Number 224'19962
(if known) (6)
Original Date of Issue 09/1 /201 6
(if known) (7)
Reason for original issue of Warrant/Check (8):
* Payroll APPROVE')
LII For Services or Goods furnished DA-r.1
Eli Treasurer's refund/payment
17.7-tf'rrti BOARD • • • •-I •-I OF '2. r- uPEr,,visn • I r-Nr
CI Other:
A,R.S. 11-632 & 11-644
Revised April 2015

Application for a Duplicate or Stale-Dated Warrant/Check
.Affidavit/Claim Form
This application is for: ti 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.
GRANT CARLOS GALAN (1), being first sworn, upon oath deposes and says:
Ninny/Claimant
On or about 094,1 /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 paymeri . 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 bezjssrled tozhi„”er in the sum of $ 130.00 .(3)
Signed: (4)
Note: 'Please'attabh-a '6opy 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 l k day of liC401)(--, 20
-
N01ARY PUBLIC/ JESSICA TANG
Notary Public - Arizona
My. commission expires: Maricopa County
020 My Comm. Expires Mar 3, 2020 (seal)
Warrant/Check Number 22417571
__Of known) (6)
Original Date of Issue 09/V1/2016
(If known) (7)
C7.
Reason for original issue of Warrant/Check (8): 7'7 C7:3
Payroll C ••••--f
D For Services or Goods furnished
Di Treasurer's refund/payment
ri Other: .I•II
J
c.--
Revised April 2015 A.R.S. 11-632 & 11-644
MARICOPA CDJN -i -v

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: it 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 MAR ICOPA Instruction sheet which is page 2 of this form.
SUSAN MARIE WEST (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09/p1/2016 (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 cr 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 yedr aller 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.
(5) Subscribed and,sworn to before me this / _.2) day of oa-Din•-• 20 it! ,
WY-PUBLIC KIM BRIMIE .....11•101I341
Notary Public. State ciArtrorta
My commission expires: My MARICOPA Commission COWRY Expires
(seal)
t(
Warrant/Check Number 22420555
(if known) (6)
Original Date of Issue 09/A, 1/2016
(if known) (7)
Reason for original issue of Warrant/Cheek (8):
M Payroll
11 For Services or Goods furnished -0
El Treasurer's refund/payment
El Other:
DAT A.R.S. 11-632 8( 11-644
Revised April 2015
= SUPERV:SUHS
,A COUNTY