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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: December 10, 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 Lisa at ext. 63619 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: gi Duplicate or ID 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. Iris V. Garcia (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/08/2015 (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/che ued to him/her in the sum of $ 1185.35 .(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. ubscribed and sworn to before me this day ofellr-AnAtfOr20 NOTARY PUBLIC R. BUSTOS Mr ,Lmission expires: Notary MARICOPA Public - State couNr( of Arizona Od9 My February Commission 8, 2019 Expires (seal) Warrant/Check Number 0022336578 (if known) (6) Original Date of Issue 12/02/2015 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll I 111 For Services or Goods furnished CO 0 Treasurer's refund/payment I=1 Other: Cu cp Revised April 2015 A.R.S. 11-632 & 11-644 2015 K, BOARD OF SUPERVISORS MARICOPA COUNTY Name Garcia,lris V Checid Issue Date 1 22336578 12/02/2015 - Regular and Overtime Earnings -- ADP Enterprise HR screen print as of: 12/10/2015 08:48 AM