080316 DUPLICATE WARRANTS 5 - HR_REDACTED.PDF

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BOARD OF SUPERVISOR' E COtT111 R S Maricopa County
MARICOP Human Resources
2616 JUL 1 9 3: 19
Memo
To: Fran McCarroll, Clerk of the Board
From: Lisa Platek for Linda Greinke
Date: July 18, 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 Linda Greinke at ext. 63770 for any
questions. Please route approved Affidavits back to County
Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.

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 MARICOPA Instruction sheet which is page 2 of this form.
Derreck Kirkendoll (1), being first sworn, upon oath deposes and says:
Warne/Claimant
On or about 07/13/2016 (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
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aliant/check be isai .(3)
(4)
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NotePle-ase 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 IT) day of 20 16
cIALILL-4W-)
NOTARY PUBLIC
My commission expires: Notary Public - State of Arizona
1.1ARICOPACOUTITY
1 1 -CC 201S My November Common 9, Expires 2018 (seal)
Warrant/Check Number 22398681
(if known) (6)
Original Date of Issue 07/13/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
III Payroll
111 For Services or Goods furnished
El Treasurer's refund/payment r--
El Other:
a si) ii; a 0 V
Revised April 2015 JU 02.016 A.R.S. 11-632 & 11-644
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