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Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: December 9, 2015
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 Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
RECEIVED
DEC 1 0 2015
Replacement Lost Warrant Form MAFtICOPA COUNTY 02/25/2015
CLERK BOARD OF SUPERVISORS
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AFFIDAVIT/NOTICE OF CLAIM r it! tr7 !")
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STATE OF ARIZONA Z515 DEC -8 P 1: 1 2
COUNTY OF MARICOPA
ERK, BOARD
MARICOPA COUNTY
M'aVeY BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:
That on the --)1(1Nd day of Def1/4611\ bed{ , 20 kc , he/she presented
to Maricopa County, for payment a claim for services rendered or supplies furnished during the
month of , said claim being in the sum of
Dollars ($ laSS • I ) in payment of which the Board of Supervisors caused the
Warrant No. Doaa, (.9 -agg to be issued on DeceinlAr , 20 t , 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. 00'4...33 (423b In the sum of $ S-c • I .
Dated: teXAISAE jr_, 20 tC Signed: nAQ-44
Affi
***A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the
replacement check.***
CHRISTIE ROOEHLING
Maricopa Notary Public- Co*Nrscri Arizona bed and sworn to before me this 0 day of
Expires 03/24/2017 11
My co mission expires:
3) 11 Jan f)
IPCTN A PPR (WA T Pi F A CP MAT! R 1PPT A CFMFMT CI-TFCK TC).