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.-\aCl&- R erki r\ 10A1 50 MAP,!COP.!, t,RD OF SUPF.RYISOR'S COUNTY Maricopa County 2015 DEC I 6 I'M 2: I 2 Human Resources Mern© To Fran McCarroll, Clerk of the Board Frorawn. Linda Widner Date: December 16, 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 Linda Widner at ext. 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 50 Duplicate or 0 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. "Trrra cka (1), being first sworn, upon oath deposes and says: On or about 101,g9/2o16— (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 $ 10,0 .(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),Ossruttli 1Id sworn_to before me this IVA- day of ____________ 20 15- . lAri6A NOTARY PUBLIC 411111I TRICIA MAGEEHON NOTARY PUBLIC - ARIZONA Maricopa County My commission expires: My Commission Expires 12.0 lq July 18, 2019 (seal) Warrant/Check Number al00000a if known) (6) 11 Original Date of Issue (if known) (7) !O-O (WO/5 Reason for original issue of Warrant/Check (8): „, ; ) IX Payroll • , . ) O For Services or Goods furnished CT O Treasurer's refund/payment O Other: APPROV-1-1157 Co Revised April 2015 DEC14 8 2J136 At A.R.S. 11-632 & 11-644 CLERK BOARD OF SUPERVISORS MARICOPA COUNTY