111815 STALE DATED WARRANTS 1.PDF

Maricopa County
Human Resources
To: Fran McCarroll, Clerk of the Board
From: Linda Widner
Date: November 5, 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 Duplicate Warrant
Thank you.
NOV O5 2015 |
MARIGOPA GOUNTY
GLERK BOARD OF SUPERVISORS

Stef,
Application for a Duplicate or Stale-Dated Warrant/ Check
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Affidavit/Claim Form Co UNS
This application is for: O Duplicate or [ml Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
Instruction sheet which is page 2 of this form.
COUNTY OF MARICOPA
Johanna Alsmadi (1), being first sworn, upon oath deposes and says:
Name/Claimant
On about 02/26/2014 (date)(2) a warrant/check was issued to the
or
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 $ 35.00 (3)
A (4)
Signed:
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
criba¢van n to before me this a (ho day of Os: be 2015.
(5)
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NOTARY PUBLIC
CLEVIECARTER
» NOTARY PUBLIC - ARIZONA
My expires: Maricopa County
5-A4-[P ea, My Conmaasion Expres (seal)
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Warrant/Check Number
002216587
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Original Date of Issue
59 = =
Reason for original issue of Warrant/Check (8):
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Payroll
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C1 For Services or Goods furnished a nn
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C) Treasurer's refund/payment
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(1 Other:
Revised April 2015 A.R.S, 11-632 & 11-644

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5	1	22	1	1	2	1542	1784	36	56	56.153214	a
5	1	22	1	1	3	1544	1707	56	34	20.767136	hy
2	1	23	0	0	0	1547	1922	66	672	-1	
3	1	23	1	0	0	1547	1922	66	672	-1	
4	1	23	1	1	0	1547	1922	66	672	-1	
5	1	23	1	1	1	1547	2590	59	4	57.567181	|
5	1	23	1	1	2	1556	2387	32	125	31.989712	Moors
5	1	23	1	1	3	1570	2235	26	138	0.000000	GAISUMAL
5	1	23	1	1	4	1578	2058	28	166	0.000000	DocuUMeire
5	1	23	1	1	5	1587	2019	21	30	45.652519	te
5	1	23	1	1	6	1590	1922	23	84	56.340218	SANE
2	1	24	0	0	0	1547	1300	104	855	-1	
3	1	24	1	0	0	1547	1300	104	855	-1	
4	1	24	1	1	0	1547	1301	66	391	-1	
5	1	24	1	1	1	1551	1599	41	93	38.250278	bee
5	1	24	1	1	2	1547	1481	66	94	0.000000	bOSG
5	1	24	1	1	3	1565	1449	36	16	52.396702	2
5	1	24	1	1	4	1567	1301	42	126	34.244556	Pag
4	1	24	1	2	0	1596	1300	55	729	-1	
5	1	24	1	2	1	1602	2017	6	12	0.000000	B
5	1	24	1	2	2	1596	1770	26	162	0.000000	AAPEPISIAN
5	1	24	1	2	3	1604	1684	23	72	8.269367	Ware
5	1	24	1	2	4	1609	1624	21	48	27.398228	sree
5	1	24	1	2	5	1611	1573	22	35	34.524307	pyle
5	1	24	1	2	6	1616	1521	20	40	50.601555	oy
5	1	24	1	2	7	1618	1455	21	56	60.205887	THE
5	1	24	1	2	8	1622	1354	25	89	38.995621	Bask,
5	1	24	1	2	9	1621	1300	30	31	16.004248	EE
4	1	24	1	3	0	1631	2152	16	3	-1	
5	1	24	1	3	1	1631	2152	16	3	67.509010	i
2	1	25	0	0	0	1621	1383	28	88	-1	
3	1	25	1	0	0	1621	1383	28	88	-1	
4	1	25	1	1	0	1621	1383	28	88	-1	
5	1	25	1	1	1	1621	1451	28	20	14.018221	st
5	1	25	1	1	2	1636	1383	8	17	21.342434	5
2	1	26	0	0	0	1576	332	52	950	-1	
3	1	26	1	0	0	1576	33	88	1249	-1	
4	1	26	1	1	0	1576	332	52	950	-1	
5	1	26	1	1	1	1576	1150	42	132	0.000000	ASSO
5	1	26	1	1	2	1584	1006	42	92	0.000000	RFE
5	1	26	1	1	3	1593	925	35	57	43.760296	Sy
5	1	26	1	1	4	1612	332	5	7	0.000000	‘
2	1	27	0	0	0	1630	952	38	310	-1	
3	1	27	1	0	0	1630	952	38	310	-1	
4	1	27	1	1	0	1630	952	38	310	-1	
5	1	27	1	1	1	1630	1176	25	86	30.503826	HOLO
5	1	27	1	1	2	1636	1125	22	39	89.339653	AT
5	1	27	1	1	3	1640	1072	21	42	82.935585	AN
5	1	27	1	1	4	1643	952	25	107	0.000000	ANGLE
2	1	28	0	0	0	1650	527	41	410	-1	
3	1	28	1	0	0	1650	527	41	410	-1	
4	1	28	1	1	0	1650	527	41	410	-1	
5	1	28	1	1	1	1650	898	20	39	91.204346	TO
5	1	28	1	1	2	1652	805	24	75	33.958351	View
5	1	28	1	1	3	1657	700	25	89	26.998339	wrap
5	1	28	1	1	4	1665	527	26	156	43.445377	CHEGICING
2	1	29	0	0	0	1655	122	63	414	-1	
3	1	29	1	0	0	1655	122	63	414	-1	
4	1	29	1	1	0	1655	122	63	414	-1	
5	1	29	1	1	1	1675	521	18	15	81.846550	G
5	1	29	1	1	2	1675	447	21	59	88.675217	THE
5	1	29	1	1	3	1655	184	56	247	0.000000	ehobasemenrr
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