100516 DUPLICATE WARRANTS 2 - HR_REDACTED.PDF

Maricopa County
Human Resources
Memo Cl,
To: Fran McCarroll, Clerk of the Board
From: Linda Greinke
Date: September 14, 2016 LO
Re: 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 Linda G. at ext. 63770 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: 1 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.
(1), being first sworn, upon oath deposes and says:
On or about VoISA?c-V4, (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 ) issu d t im/her in the sum of $ 3 9 3 I 13 .( 3 )
Hinneedd:: ) -4 (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 f day of -eot 20 if-(
NOTARY PUBLIC
MATTHEW A. GLIRBAS
4 Notary Public • Arizona
My commission expires: Mairicopa County
67// 3/dt) 1 6( My Comm. Expires 1,113, NE%
•
Warrant/Check Number
(if known) (6) 21 () Ir.-Dap z ti
Original Date of Issue
(if known) (7) APPROVED
Reason for original issue of Warrant/Check (8):
Payroll
0 For Services or Goods furnished
El Treasurer's refund/payment
0 Other:
Revised April 2015 A.R.S. 11-632 & 11-644