080316 DUPLICATE WARRANTS 2 - HR_REDACTED.PDF

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BOARD OF SUPERVISOR'S Maricopa County
HARICOP
Human Resources
HAS JUL 15 pn 1:
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: July 15,2016
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 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: Iii Duplicate or El Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond 10 numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Cecilio 0 Barajas (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05/17/2016 (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
warrant/check be issued to him/her in the sum of $ 140.00 .(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.
( Subscribed and sworn to 13, 20
(in/LOA/A
NOTARY PUBLIC
BREANNON A CARLSON
M ommission expir Notary Public - Arizona
h 430 Mane opa County (seal)
My Comm. Expires Mar 17, 2019
6
Warrant/Check Number 22385548
(if known) (_6) Crs
Original Date of Issue 05/22/2016 16:7-.1 / 6,
(if known) (7)
cio±u
Reason for original issue of Warrant/Check (8): APPROVED
w Payroll JUN. 5 NZ
El For Services or Goods furnished
I=1 Treasurer's refund/payment
El Other:
Revised April 2015 A,R.S. 11-632 & 11-644