072016 DUPLICATE WARRANTS 6 - HR_REDACTED.PDF

CLERK
BOARD HARICOP OF SUPERVISOR'S A COUNT Y Maricopa County
2016 JUL -1 PM 12: 30 Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Milliron
Date: July 1,2016
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/Claim Form
•
This application is for: Duplicate Or LIII 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.
Ryan Gossett (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 06/01/2016 (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, a 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 theainountAlWaill..1.1sid owing, and the applicant requests that a reicerirent
warrchtiche issu to him&r in the sum of $ 396 . 99
Signed: (4) Q
Note: Plese attach a copy of the warrant/check if available and/or rtst, o#7er
evidence that a warrant/check- was originally issued. rn
(5) 5, b c becl and/w7rn to before me this .„-.2Crl day of )6iie 20 lb .
(
NOTARY PUBLIC
LENE POPE
Mary - State clArizoni
My commission expires: KAFKOPA COUNTY
4ptIL Lf i MyCommitsfon Wire, Apr. 4. 207 (seal)
Warrant/Check Number o /2/2-gs 661 5
(if known) (6)
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
El For Services or Goods furnished
CI Treasurer's refund/payment
LI Other:
APPROVED
Revised April 2015 A.R.S. 11-632 & 11-644
j 01 2015`
EnK, BOARD OF SUPERVISORS
MPOICOPA COUNTY

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