090716 DUPLICATE WARRANTS 4 - HR_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: August 5, 2016
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 Debbie M. at ext. 62406 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/Caim Form
This application is for: 0 Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF RIZONA Note; Numbers on this form correspond to numbers on the
COUNTY OF IV1ARICOPA Instruction sheet which is page 2 of this form.
. c;Ilekot L.9 3 (1), being first sworn, upon oath deposes and says:
Nameicliainn am "4(1411
On or about 7-2,7- (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 rE ceived 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 vvithin one year after the date of issuance.
Therefore, uncer penalty of perjury, claimant hereby affirms that this claim is correct
and the amour t shown is due and owing, and the applicant requests that a replacement
warrant/check be issued to him/her in the sum of $ 5- 3o, 0 .(3)
Signed: (4)
Note: Pleise attach a copy of the warrant/check if available and/or any other
evidence ti at a warrant/check- was originally Issued,
(5) SubscrilIed and sworn to before me this L-1 day of
Ittu/kluttoCailelk
NOTARY PUBLIC
EILEEN W1LLLAMSPRJW
New/hoc- gele of Arizona
My commis 3ion expires: MARICOPA COUNTY
II flitt 14g My November Commission 0, 2018 ecil'es (seal)
Warrant/Check Number
(if known) (6) 0.(n-aq0
Original Date cf Issue
(if knowr ) (7)
ReasoVor oriclinal issue of Warrant/Check (8):
Payroll
0 For Sell ices or Goods furnished AN 6 2016
DA.
LI Treasurgis refund/payment
Otaferzitvalow
0 Other:
Revised April 2015 A.R.& 11-632 8.11-644