Extracted text (via tesseract_tsv)
23981 characters
= Maricopa County
Human Resources
Viemo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: September 4, 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.
Pro paxomap pyr
Replacement Lost Warrant Form 1 €Z:f Wd I-
5 1 16 1 1 9 1948 2861 78 89 0.000000 d35
5 1 16 1 1 10 2040 2865 127 74 21.698719 As
2 1 17 0 0 0 1870 2970 284 89 -1
3 1 17 1 0 0 1870 2970 284 89 -1
4 1 17 1 1 0 1904 2970 190 46 -1
5 1 17 1 1 1 1904 2970 190 46 0.000000 gooldv
4 1 17 1 2 0 1870 2988 284 71 -1
5 1 17 1 2 1 1870 2988 49 71 59.629166 ne
5 1 17 1 2 2 1940 3019 46 35 53.225479 4o
5 1 17 1 2 3 2008 3004 146 43 8.694162 Guvoe
2 1 18 0 0 0 1850 3061 116 44 -1
3 1 18 1 0 0 1850 3061 116 44 -1
4 1 18 1 1 0 1850 3061 116 44 -1
5 1 18 1 1 1 1850 3061 116 44 24.270077 ¥a19
2 1 19 0 0 0 1826 2993 20 31 -1
3 1 19 1 0 0 1826 2993 20 31 -1
4 1 19 1 1 0 1826 2993 20 31 -1
5 1 19 1 1 1 1826 2993 20 31 43.937752 Oo
2 1 20 0 0 0 1676 2998 188 72 -1
3 1 20 1 0 0 1676 2998 188 72 -1
4 1 20 1 1 0 1755 2998 63 32 -1
5 1 20 1 1 1 1755 2998 63 32 0.000000 ifO
4 1 20 1 2 0 1676 3002 188 68 -1
5 1 20 1 2 1 1676 3006 21 31 75.360428 A
5 1 20 1 2 2 1713 3002 45 68 19.808836 Lt
5 1 20 1 2 3 1794 3030 70 30 41.236740 vad
2 1 21 0 0 0 1614 3039 198 83 -1
3 1 21 1 0 0 1614 3039 198 83 -1
4 1 21 1 1 0 1618 3039 194 42 -1
5 1 21 1 1 1 1618 3044 92 37 1.246195 S,¥0
5 1 21 1 1 2 1722 3039 90 33 0.000000 SJAG
4 1 21 1 2 0 1614 3102 32 20 -1
5 1 21 1 2 1 1614 3102 32 20 27.164106 V3
2 1 22 0 0 0 1815 3033 25 75 -1
3 1 22 1 0 0 1815 3033 25 75 -1
4 1 22 1 1 0 1815 3033 25 75 -1
5 1 22 1 1 1 1815 3033 25 75 25.315289 wet)
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: O Duplicate or 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.
Monique Williams (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 12/3/2014 (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 is due and owing, and the applicant requests that a replacement
amounthown
warrant/check be issued to him/her in the sum of $ 115.00 (3)
as
Signed: i (4)
vA 4 =
« Note: Ple a copy’of the warrant/check if available and/or any other
evi ence that a warrant/check was originally issued.
~~
(5) Subscribed ands orn to iathis Z7 day of hegust 20 /S
m JESUS R. ARELLANO
A, NOTARY PUBLIC - ARIZONA
j MARICOPA COUNTY
My Commission Expires
Getober 25,2015 pero (seal)
(if known) (6)
Original Date of Issue
SI
NVWNH
Reason for original issue of Warrant/Check (8):
ds
Payroll
I-
LC For Services or Goods furnished
Wd
11 Treasurer's refund/payment $39YUNOb3Y
11 Other: 2:3
Revised April 2015 A.R.S. 11-632 & 11-644
Aug 17 2015 9:17PM HP Fax page 1
Stale Dated Check Claims
1. Please provide a Statement
validating that there is good and
Sufficient reason for not presenting the
original
Wwarrant/check for payment before the voided d
a= Never CeCieved
€ Rieck
2. Where would you like us to mail the
replacement
3. If available, please attach th
@ Original warrant/check
copy along with the notarize 0 or a
affidavit and this form to:
Maricopa County Elections
Dept.
Attn: Payroll Division
111 S. 34 Ave. Suite102
Phoenix, AZ 85003-2294
ease contact Deyan Bunjevic
at 602-506-2471
rett at 602-506-2499 or Lorraine
if you have any questions.
{ Paycheck View
-Name Williams,Monique Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
22240783 12/03/2014 115.00 115.00
- Regularand Overtime Earnings - Taxes
Reg Hours Reg. Pay OT Hours OT Pay
~ Other Earnings c= Deductions
|
|
|
|
ADP Enterprise HR screen print as of: 08/20/2015 08:41 AM
06/17/15
Comments by ADP
returned
funds
Returned Ck #
on
YEAR 2015 by
1 30, Returned ADP
766 June _
FUND CHECKS WITHIN
Through Amount 115.00
ACCT
PAYROLL OUTSTANDING 2014 S
PAYROLL ADP 1, July
CHECKS Date Name
Issue
Employee Monique
\itians
Id
Employee EE
Date 12/3/2014
Check
Number 22240783
Check
MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: September 9, 2015
To: Clerk of the Board
From: Joyce Maurmann
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached 1 Affidavit for lost warrant to be included on the next available
Board Agenda.
e The attached items have been researched to ensure the warrant in
question have not been cashed or previously re-issued.
e The original warrants have a void/stale date/stop payment done.
Please call me at 506-1343 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Westgroup Research
Gyo yoap yet
6- 48 St
neg WY
amps wyH.
Sg. BOSSE I19
Va
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit /Claim Form
This application is for: Duplicate or L] stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
numbers on the Instruction sheet which is
COUNTY OF MARICOPA
paae 2 of this form.
Westgroup Research (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 21-Jul-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 him/her in the sum of $ 12,000.00 (3)
Signed Sarorna Lea Phra, abfica [rosps ol Suasp fhasoich (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Subscribed and methis__\___day of Sepkim ber 20(5_.
(5)
ae y
ij
(NOTARY PUBLIC | (>
SHELLY OZUNA
Public - State of Arizona
My commission os expires: ; MARICOPA COUNTY
i 201 aT | (seal)
Reef
360001890
t incaiie
Original Date of Issue 21-Jul-2015
roe G
Reason for original issue of Warrant/Check (8):
1 Payroll
For Services or Goods furnished
1 Treasurer's refund/payment
(1 Other:
WestGroup
U
RESEARCH
September 1, 2015
Department of Finance
Maricopa County
301 W. Jefferson, Suite 960
Phoenix, AZ 85003-2906
Re: WestGroup LLC
EIN: 47-3428456
Please be advised that the following employee of WestGroup LLC is authorized to sign
on behalf of WestGroup:
Sharon Lee Mora,
Office Manager
Please direct any questions to the undersigned at
Glenn@westgroupresearch.com 602-707-0053.
Sincerely,
Glenn Iwata
President
3033 North 44h Street, Suite 150 Phoenix, Arizona 85018
Main: 602.707.0050 Toll Free: 800.999.1200 Fax: 602.707.0055
www. WestGroupResearch.com
MARICOPA COUNTY Bo 09 OF Sure RvisaR's
|
Department of Finance
301 West Jefferson, Ste960 ‘2013 SEP-9 AN 9:44
Phoenix, Arizona 85003 tndivirelual rig
INTEROFFICE MEMORANDUM
Date: September 9, 2015
To: Clerk of the Board
From: Joyce Maurmann
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached 3 Affidavits for lost warrants to be included on the next available
Board Agenda.
e The attached items have been researched to ensure the warrant in
question have not been cashed or previously re-issued.
e The original warrants have a void/stale date/stop payment done.
Please call me at 506-1343 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Kaia Moe
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 1 stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
sheet which is
COUNTY OF MARICOPA See neta eae
Kaia Moe (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 15-Jan-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 him/her in the sum of $ 38.00 (3)
Signed: Bo (4)
F
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued. Suluam nah 4 wed .
ZL.
(5) Subscribed and sworn to before me this LY h day of lv Ao 20/2.
“NOTARY PUBLIC
My commission expires: HOD uo COUNTY
eprudy 24,0! v . weecatser | (seal
4
Warrant/Check Number 7456
35001
(if known) (6)
Original Date of Issue
Reason for original issue of Warrant/Check (8): |
1 Payroll
O For Services or Goods furnished
1 Treasurer’s refund/payment
See
«othe:
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
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
COUNTY OF MARICOPA
paae 2 of this form.
Kaia . Moe (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-Feb-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 him/her in the sum of ¢ 38.00 (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. (walled t Me bp Sid\en)
Subscribed and sworn to before me this L| Y day of Aa 20/ “ >
’
SI
oA
-—ee
NOTARY PUBLIC RIVAS
DOMINIGUE
MoE OR COUNTY
M mission exp My Commission Expires
re. DY OL WATE? ig | / 20Ue Y pobruary 24, 2016 (seal)
Warrant/Check Number
350019746
(if known) (6)
Original Date of Issue 05-Feb-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
CO For Services or Goods furnished
1 Treasurer's refund/payment
Jury per diem
Lather
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
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
COUNTY OF MARICOPA
paae 2 of this form.
Kaia . Moe (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11-Feb-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 him/her in the sum of $ 38.00 (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. ( wit t Mw KE Ahoy
Subscribed and sworn to before me this th day of VY A 20_/ >
(5)
! Lt
ae |
NN RY PUBLIC ! DOMINIQUE RIVAS
Me OO OPROOUNTY
My commission expires: My Commission Expires
Fi ChyVUar SY , 20) (g February 24, 2016 (seal)
4
Warrant/Check Number 350020220
(if known) (6)
Original Date of Issue 11-Feb-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
1 Payroll
1 For Services or Goods furnished
O1 Treasurer's refund/payment
Other: Jury per diem
1
Maricopa County
Clerk of the Board of Supervisors
Date: “\ lo loots
301 W. Jefferson St, 10% FI.
Phoenix, Arizona 85003-2148
Phone: (602) 506-3766 Subject: Duplicate Warrant or Stale Dated Warrant
Fax: (602) 506-6402
www.maricopa.gov
The document(s) have been returned to your office Ww TOUS Boro rettbee
L) Name/Claimant name is missing or does not match backup documents
L} Original Date of Issue is missing or does not match backup documents
(1 Amount of check is missing or does not match backup documents
(| Warrant/Check number is missing or does not match backup documents
4 ~=Claimant signature is missing or does not match Name/Claimant name
(| ~=Notary signature and/or seal is missing
(| Documents stating that the Name/Claimant is eligible to sign the
Affidavit/Claim Form were not provided
Other: Please Ye hude OH Cover shock tA be Sore
as
Pre documercts ane, woted. paok to Wu
RECEIVE
SEP 09 2015
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
imer office mar/
HL6,
Gohunls?
AFFIDAVIT
a
STATE OF ARIZONA
COUNTY OF MARICOPA
MOK ine Ange | being duly sworn, upon oath deposes and says:
\r
That on the ot day of NoOVE moe ie Bol YU he/she presented to
,
the Avondale Elementary School District of Maricopa County, for payment, a claim for services
rendered or supplies furnished during the month of Novlemberc gol Y said claim being the
, ,
. . : bo) a4 .
sum of ON¢Tawotiid +wo huninad. dollars (gl alo.r7q ) in payment of which the
foray
Superintendent of Schools caused his/her Warrant Number (3-00 S2UCU to be issued on
molemaw 20, ac si drawn on the © DC©_ Fund of Avondale Elementary School District of
,
Maricopa County, Arizona.
Claimant further says that although he/she was informed and believed that the above-
mentioned warrant was regularly issued, the same has never been received or has been lost. Under
penalty of perjury, claimant hereby affirms that this claim is correct and the amount shown is due
and owing.
Wherefore, claimant requests that the Board of Supervisors order and in the Superintendent
of Schools issue him/her a duplicate of Warrant Number (5-00S2.UO6 _ in the sum of
$ lado mel
\
Claimant Signature Ls
; Wh
and sworn befgfe me this__ A L day of
“CH
Ca
~~, 44 My commission expires:
otary Public)
// J
¢
Seal:
cn cee sapees oem es man st mms naman eens De SS SE NS ey
OFFICIAL SEAL 1
LAURA VERA i
B| 2) \z) Notary Public - State of Arizona j
S74) MARICOPACOUNTY
My Comm. Expires Aug. 31, 2017 |
Following approval please return this affidavit to Maricopa County Education Service Agency
Schools Affidavit/Claim Form
Application for a Duplicate Warrant/Check (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.
CHRISTINE LUKSIK (1), being first sworn, upon oath deposes and says:
Name/Claimant
;
On or about S/: Z2f/5_ (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 $ 139.52 (3)
I ae ot Fe
Signed: é. (4)
ae
(5) Subscribed and sworn to before me this ah” day of At ( Ast 2015.
Age
NOTARY PUBLIC
LISA DEAN-LLERENAS
My commission expires: eats } ‘a Notary Public - Arizona
Js} Maricopa County
(seal)
A Expires 08/16/2018
‘Seeestenreemenyeirretinraes ne eet
Note, Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Warrant/Check Number A
450093136 f
(if known) (6)
Original Date of Issue
9/22/11 0
(if known) (7)
Reason for original issue of Warrant/Check (8):
C1 Payroll
RETIREE REIMBURSEMENT
CO For Services or Goods furnished
m@ Other: RETIREE REIMBURSEMENT
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999
AFFIDAVIT
|
STATE OF ARIZONA
COUNTY OF MARICOPA
Kim era Aukke
being first duly sworn, upon oath deposes and says:
AName and Title of Person)
/S Phx Chev Sch Nigt™/
That on Mug ae | 20 he/she presented to of
(School District Name)
Maricopa = Arizona, for a claim for services rendered or supplies furnished during the
payment,
month of G 20 IS. said claim being in the sum of (SASE, ¢/ )
, ,
sided Sith Zand Va
we — Dollars in payment of which
the Superintendent of Schools caused his/her Warrant Number Je - 0002 oS: SEG to be issued
e 907% . Qo! cund i Gen Sch Dist of
on Aug drawn onthe of
(School District Name)
county,
Maricopa Arizona.
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.
WHEREFORE, affiant prays that the Board of Supervisors order and the Superintendent of Schools issue
to him/her a duplicate of said Warrant Number Le LO0sS8 b in the sum of $ ASO: Z/
vA
Signed:
(Name and Titléof wr Authorized Personnel)
mn \5
Subscribed and sworn to before me this _— a __ dayof AAR , 20
!
A Do Dea
NA 6d
NOTARY PUBLIC: a
£4. | lived :
My commission expires: LISA DEAN-LLERENAS
ga'*\ Notary Public - Arizona
= Maricopa County
Expires 08/16/2018
— eee
Following approval please return this affidavit to the Maricopa County Education Service Agency Office.
Maricopa County
Clerk of the Board of Supervisors
Rates 4 | |
301 W. Jefferson St, 10% FI. ( M\9
Phoenix, Arizona 85003-2148
Phone: (602) 506-3766 Subject: Duplicate Warrant or Stale Dated Warrant
Fax: (602) 506-6402
Wwww.maricopa.gov
The document(s) have been returned to your office withoutapproval-because:
ao Name/Claimant name is missing or does not match backup documents
Original Date of Issue is missing or does not match backup documents
Amount of check is missing or does not match backup documents
OOoodoao Warrant/Check number is missing or does not match backup documents
Claimant signature is missing or does not match Name/Claimant name
Notary signature and/or seal is missing
Documents stating that the Name/Claimant is eligible to sign the
Affidavit/Claim Form were not provided
Other: Se clude > ao Cover Macf —o ensore—
\y
he wn. youfed to dhe
documonds berry
Correct da par houct
thank
RECEIVED
SEP 1 1 2615
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
1/0 mat!
on
AFFIDAVIT
STATE OF ARIZONA Pitcoke
COUNTY OF MARICOPA
Comte
* Dy) Leder eC CS
, being first duly sworn, upon oath deposes and says:
(name and title of person )*
That on the Li, day of Svohemlboe C 20 |D he/she presented to
,
A\ngun bors ra hor LSiSHC+
District of Maricopa County, Arizona , for payment, a claim for services rendered or supplies shed
jon
during the month of \ SF 20 5 _, said claim being in the sum of (S (OS. U2 )
om
Duxty- + Wee Wallac Ss Cond Cv Ye Cents,
ry ) Dollars in payment of
Which the Superintendent of Schools caused his/her Warrant Number I . Oo O SX to be
Issued on the Osh a ogst 205, drawn on the 030 Fund of fl] hae bre Se hol
District of Maricopa County , Arizona.
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.
WHEREFORE, affiant prays that the Board of Supervisors order and the Superintendent of Schools issue
to him/her a duplicate of said Warrant Number {(o0 |A5%% __ in the sum of $ (93.49
OFAC ODER |
signet LA %, CHERYL CARDER
LC WM texzce S Notary Public - State
&} MARICOPACOUNTY
My Comm. Expires Aug. 42, 2017 |
(Name & title of authorized personnel)**
Yih <, phe ber [=
Subscribed and sworn to before me this, day of (\\ 20
,
WE Copbe
‘ Qey/
NOTARY PUBLIC :
/ [20 9
My commission expires: 2
Following approval please return this affidavit to the Maricopa County Education Service Agency Office.
INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency
TO: Clerk of the Board
From Susana Fraire/Elsa Perez
SUBJECT: Affidavits — Replacement of Lost /Stale Warrants
DATE: 9/9/2015
Please find attached__ Affidavit/Notice of Claim(s) for lost warrants for inclusion on
the next available Board agenda.
V The attached item(s) have been researched to ensure that the warrant(s) in
question have not been cashed or previously re-issued.
V The original warrant(s) have had a stop payment done.
If you have any questions, please contact Susana Fraire/Elsa Perez at (602) 372-8425
or (602) 506-3533 or via e-mail at garnishments@mcesa.maricopa.gov. Approved
Affidavits may be routed back, to the Maricopa County Education Service Agency at
4041 N. Central Avenue #1200, ( 12 Floor) Thank you.
Fund 781 Employee Name $0.00
SEP 1 § 2015
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: {ma Duplicate or LJ 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.
SELESE COVARRUBIO (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 98/20/2015 (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
(3)
(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) Subscribed and swarn to before me this SG | | \ day of =? Qlember20 [5.
Ae LOA OU1CA__)
PAO
TARY PUBLIC“
My commission expires:
20 |
Warrant/Check Number
160011581
check Nu
Original Date of Issue
08/20/2015
(if known) (7)
Reason for original issue of Warrant/Check (8): | APPROVED
f=] Payroll SEP\L 5 201
DATE,
O1 For Services or Goods furnished
:
11 Treasurer's refund/payment Baik, BOARD OF Su
(1 Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644