060816 DUPLICATE WARRANTS - 3.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Linda Widner
Date: May 12,2016
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 W. at ext. 68051 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
Stale Dated 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: 0 Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 111 111 on this 1c1r11 correspond to II on the
COUNTY OF MARICOPA 11....1 111 lv,r1-1 is page 2 of 1r
), being first sworn, upon oath deposes and says:
ame/Clatman
On or about ioLl 12k..)(n (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 $ .(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 t2- day of 20
owaUct".
?wx#46
NOTARY PUBLIC
El N WILLIAMS- S
My commission expires . Notary Pubic - Stab (Mims
kk • °A - S My MARCUM Commission COUNTY &Ores (seal)
November 0, 2018
Warrant/Check Number
(if known) (6)
Original Date of Issue
(if known) (7) Sioe-i/2_6(n
Reason for original issue of Warrant/Check (8):
lig Payroll
CI For Services or Goods furnished
0 Treasurer's refund/payment
C)
111 Other: ZC'
APPROVE fl rr C)
Revised April 2015 MA 3 2016 A.R.S. 11-632 (,) 81'1-1-644 ,N?
DAT
ERK. BOARD F SU
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