081716 DUPLICATE WARRANTS 5 - HR_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Upton
Date: August 1, 2016
Re: Replacement of Lost Payroll Warrants
Please find attached I 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
This application is for: 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 MARICCPA Instruction sheet which is page 2 of this form.
titv1Paint1)-"' - (1), being first sworn, upon oath deposes and says:
On or about ()I - 21 - I(-) (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 ciit vvcas not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claini is correct
and the amount shown is due and owing, and the applicant requests that a rpplac -nent
_ )
warrant/check be issued to him/her in the sum of $ 2-- b
Signed: (4)
Note: Plewse attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscrib d and sworn to before me this :--)u '7 A 1-1-, - day of cru L 20 ib .
(--- /.) , 0,0111188, f
• .________ 0 0,t, ?I us -4. • o
NOTARY PUBLIC % $"%froV.Z.r". ,r- ' 0:" / ... 4. usugAs . I. ..- • 0
... et 4: i IV 00 .1,10A1411,, I0 AI: 1:
My commission expires: ,„,,, • c) z 45,0 v's .
•• coN. ,..t e. t; f 1 c 1.i. (seal)
It, •.• cow .
...,' 1 .t. .
Warrant/Check (if known) Number (6) 00 2 - - 7. 4 0 2-1-ii z---01%/11;?7•A;sel-r*'5A°- hint o 110—
-
Original Date of Issue
(if known) (7)
Reaso9/for original issue of Warrant/Check (8):
Payroll
El For Services or Goods furnished
111 Treasurer's refund/payment
El Other:
CAUsers\williamse\AppDatakLocal\Microsoft\Windows\Temparary Internet Files\Content.Outlook\FITTOL74G IWarrants Checks notice
of claim.doc
Revised April 2015 A.R.S. 11-632 & 11-644