060816 DUPLICATE WARRANTS - 8_REDACTED - HR.PDF

Of S-OPZI),`il'S SOR
BoA IANP,ICO? RD COUW Maricopa County
20 ?IA 3:41 Human Resources
Nit lir(
Memo
To: Fran McCarroll, Clerk of the Board
From: Debbie Upton
Date: May 20, 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 U. at ext. 66329 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: LI Duplicate or LI 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.
LarQ)Ack COvv\vp 0.1 (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 5- 11S 12g(p (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
warranticheck)be issued to him/her in the sum of $ )0“ , .(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 20 day of H a-4.-)- 2O R (,6) ' .
NOTARY PUBLIC
elLEEN WILLIAMS-PREAS
My commission expires: Notary MARICOPA Pubilo • Style COUNTY of Moms
- c)--0 MY November CorrIression 9, 2018 Expires (seal)
Warrant/Check Number 2.73S105-0
(if known) (6)
Original Date of Issue
(if known) (7)
Reaso,for original issue of Warrant/Check (8):
vi Payroll
Ell For Services or Goods furnished
0 Treasurer's refundirpayment
El Other:
C: \Users \williamse\AppData \Local \Microsoft \Windows \Tempera ry Internet Files \Content.Outlook\HTTDL74G \Warrants Checks notice
of claim.doc
Revised April 2015 A.R.S. 11-632 & 11-644

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Paycheck View mings iaxes 1111P4410.9 Distributions,
Name Campos,Launa N Confirmed Check
Check 4 Issue Date Earnings Taxes Deductions Net Pay
05/1812016 1,068.85
Regular and Overtime Earnings
ADP Enterprise HR screen print as of: 05120/2016 02:43 PM