062216 DUPLICATE WARRANTS - 5 REDACTED - HR.PDF

BOARD MARICOP OF SUPERVISOR'S COUNT Y Maricopa County
Human Resources
26 JU1-1 -7 AM 12: 10
Memo
To: Fran McCarroll, Clerk of the Board
From: Lisa Platek
Date: June 6, 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 Lisa P. at ext. 63619 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

APPROVED
DATE
AFFIDAVIT/NOTICE OF CLAIM , •
BSA DO SUP
MARICOPA COUNTY
STATE OF ARIZONA 16 JUN -6 Mil: 05
COUNTY OF MAR1COPA HUNAN RESOURCES
11--ctam 5. UN
BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:
6
That on the day of , 20 1 (e , he/she presented
to Maricopa County, for payment a claim for services rendered or supplies furnished during the
Dollars ($ T7 4{ , in payment of which the Board of Supervisors caused the
Warrant No. V-W52-151 to be issued on 74141 , 20 (5 , drawn on the
Payroll Clearing Account fund.
Affiant further says that although he/she was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost. Under penalty of
perjury, affiant hereby affirms that this claim is correct and the amount shown is due and owing.
WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said
Warrant No. 7,--.2-1305-1-b In the sum of $ Uri Lktra
Dated: ,20 r/-,6 Signed: _
Affiant
***A $12.00 fee for the stop payment and reissuanee of the warrant will be deducted from the
replacement check.'''''"
Subscribed and sworn to before me this day of jUrvki. , 20 110
Notary Public
My commission expires: r---.-'"—TMOMMEMW AIM El
Notary fur*. aided hum
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Paycheck View MCY-Ea rnings .t: -Taxes - Deductions Garnishñhts ismoutionar,
Name Rowley,Adam S Confirmed Check
Checkti Issue Dat€ Earning Taxes Deduction5 Net Pay
22305251 0812612015 1,673.4d
Reaularand Overtime Earnings Taxes
OtherEarninqs =11 r Deductions
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