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| Maricopa County Human Resources To: Fran McCarroll, Clerk of the Board From: Linda Widner Date: October 15, 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. OCT 16 20% MARICOFA COL SO IPERVIS ORS CLERK BOARD OF Maricopa County Human Resoutces Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix, AZ 85003-2143 DATE: [O- / S-/ Ss Phone: 602-506-3519 Payzoll Fax: 602-372-0277 . ate : . vane Records Fax: 602-506-5509 TO: Eileen Williams/Debbie Milliron www. marncopa.gov - FROM: 770) ; RE: Stop Payment on Warrant Please place a stop payment on the Warrant listed below. It has been determined that the Warrant is outstanding as of this date: A a i) 8259 Warrant Number: Issue Date: [0 -7-! Ss __ Soros Co Marbinwe Payable to: SIS. 7S Amount: NUE Statue Reason for Stop Payment: Attach a print screen of the paycheck view. hub) DW Authorized Signature — Payroll Specialist Date Stopped Stopped by Transaction Number Time Stopped Warrant/Check Soe Application for a Duplicate or Stale-Dated Affidavit/Claim Form Crap” This application is for: Duplicate or [_] 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 Sarah Marban (1), being first sworn, upon oath deposes and says: ~~ Name/Claimant On or about 10/7/2015 (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/check be issued to imgher in the sum of $ 815.75 (3) Signed: 722 (4) Note. Please a a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this \5 day of Oct 2015. NOTARY PUBLIC My commission expires; WO QOS (seal) Warrant/Check Number 0022318259 (if known) (6) Original Date of Issue 10/07/2015 a (if known) (7) s197 Reason for original issue of Warrant/Check (8): 3 130 pened t j=] Payroll an SI . O For Services or Goods furnished W FA od Nod O Treasurer's refund/payment Chth 1) Other: Revised April 2015 A.R.S. 11-632 & 11-644 io /15 JI5 My mame is) SaraW Marban and 2 have fecieved it.