090915 ADDITIONAL DUPLICATE WARRANTS.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Linda Greinke
Date: September 2, 2015
Re: Replacement of Lost Payroll Warrants
Please find attached _ 2 _ 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 G. at ext. 63770 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
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Thank you.
RECEIVED
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MARICOPA COUNTY
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Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: Mas 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
ied Seaovic (1), being first sworn, upon oath deposes and says:
Name/Claimant (
On about (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 $ L U9 7-o (3)
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(4)
Signed: _} __-
Se” N
Note, Please rach copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
d and sworn to before me this (5+ _day of Srytonbs 20(S .
(5)
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NOTARY PUBLIC MARGIE G. TORRES
3 MARICOPA COUNTE
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My commission expires: My Colmer 17, 2016
—(1-?el& (seal) sea
Warrant/Check Number © re
o 22S O05 é UY l
(if known) (6)
Original Date of Issue B/Cb j .
VA LOLS =.
(if known) (7)
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Reason for original issue of Warrant/Check (8): = ra
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4 Payroll 2
© For Services or Goods furnished = 5
Es =
C1 Treasurer's refund/payment
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ARS.
5	1	50	1	1	2	1941	2956	96	26	93.292206	11-632
5	1	50	1	1	3	2049	2956	21	24	93.273064	&
5	1	50	1	1	4	2082	2954	96	26	86.863266	11-644
2	1	51	0	0	0	351	2976	256	32	-1	
3	1	51	1	0	0	351	2976	256	32	-1	
4	1	51	1	1	0	351	2976	256	32	-1	
5	1	51	1	1	1	351	2977	104	26	96.527649	Revised
5	1	51	1	1	2	468	2976	60	32	96.366745	April
5	1	51	1	1	3	540	2976	67	25	96.366745	2015
2	1	52	0	0	0	1014	2883	637	319	-1	
3	1	52	1	0	0	1014	2883	637	319	-1	
4	1	52	1	1	0	1014	2883	637	319	-1	
5	1	52	1	1	1	1014	2883	637	319	95.000000	 
2	1	53	0	0	0	2227	2194	37	221	-1	
3	1	53	1	0	0	2227	2194	37	221	-1	
4	1	53	1	1	0	2227	2194	37	221	-1	
5	1	53	1	1	1	2227	2194	37	221	95.000000

(- Ener View
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a Name Daniel T _ Confirmed - : Check
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~ Check Issue Date Earnings Taxes _ Deductions _ NetPay |
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Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or CJ 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.
Esdras M, Rivera (1), being first sworn, upon oath deposes and says:
me. |
On or about 98/26/2015 (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 $ 1,431.23 (3)
Signed: oe oS (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 sworn to before me this [s¢ day of Swot b 20/5,
ph [Bi
NOTARY PUBLIC)
FT, MARGIE G. TORRES
\ Notary Public - State of Arizona
89/) MARICOPA COUNTY
My commission expires: “My Commission Expires
A—-1 7 Desl& September 17, 2016 (seal)
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———————
Warrant/Check Number
0022305258
(if known) (6) —
Original Date of Issue on
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Reason for original issue of Warrant/Check (8): pd uy
Payroll os
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1 For Services or Goods furnished S xs
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11 Treasurer's refund/payment LA, =
1] Other:
Revised April 2015 A.R.S, 11-632 & 11-644

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Paycheck View.
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| Name Rivera,Esdras M Confirmed Check
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Check# _ Issue Date Deductions © Net Pay
22305208 08/26/2015 1,431.23.
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Code H Amounts Add to Gross Es
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