DUPLICATE WARRANTS - 6_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board C7.)
From: Linda Greinke
Date: January 22, 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 G. at ext. 63770 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant (Duplicate Warrant
Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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.
(1), being first sworn, upon oath deposes and says:
On or about :V/ (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
warrantichn9;b issued to hinn/h94p tine/sum of $ 6)9'`.:R 7 ,(3)
(4)
Note: Please attach a copy of the warrancheck if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to b re me this rzA-11\ day of alnLiC,F 20 RP .
NOTARY P IC r-----NESSATRUJILLO
mw.pulaw-stateekuola
arocoPAcouirre
M y commission ExPiro
tbitil 20. 2°19
Warrant/Check Number 222 ,3(C)
(if known) (6)
Original Date of Issue 3/u1/20 -/ -
_(if known) (7)
Reaso or original issue of Warrant/Check (8):
Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
O Other:
Cr 1
Revised April 2015 A.R.S. 11-632 & 11-644
F1K, BOARD OF SUPEPIV3SORS
MARCOPACOUNT

r Paycheck View 'ICY-Earnings Taxes Deductions Garnishments r Special Accumulators Distributions I
Name Robbins,Bibianria L Check
Issue Date Earnings Taxes Deductions Net Pay
03/11/2015 69.27
RomilaranriOuPrtarnol-nrninn
ADP Enterprise HR screen print as of: 0112512016 02:31 PM