080316 DUPLICATE WARRANTS 6 - HR_REDACTED.PDF

Ct4 6Q-X IX oa
C LE R k-
BOARD MARICOPA OF SUPERVISOR'S Maricopa County
21115 JUL 19 PM 3: 19 Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
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 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: El Duplicate or El Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
OUNTY1 OF M4JC0PA Instruction sheet which is page 2 of this form.
(1), being first sworn, upon oath deposes and says:
ame Clai an"
On or about 7-13 —I 6 (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 $ e g - .(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.
(5) Subscribed and sworn to before me this 19 day of juaii) 20 16 .
qui,u2nadiucvyv YuD
NOTARY PUBLIC
My commission expires:
ri ,()tpls (seal)
Warrant/Check Number 4e)
(if known) (6) 4.A 99á't
Original Date of Issue
(if known) (7) 7-/.3-14
0 2i116
Reayfor original issue of Warrant/Check (8):
Payroll
0 For Services or Goods furnished
0 Treasin-priQrfi inri/navmprit
Other
C: \Users \williamse\AppData \Local \Microsoft\Windows\Temporary Internet Files\Content.Outlook\H11OL74G\Warrants Checks notice
of ciaim.doc
Revised April 2015 A.R.S. 11-632 & 11-644