STAMPED & REDACTED TAYTEM STRAUEL_REDACTED.PDF

Maricopa County
Human Resources

Memo Fe

To: Juanita Garza, Clerk of the Board RS
From: Lisa Platek oo
Date: May 12, 2022 -
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 Lisa P at ext. 63619 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

—

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: NS oupreate or L] 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.

Teytem CHawel (1), being first sworn, upon oath deposes and says:

Nafne/Claimant

On or about _X7 April id KC (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, G GO . IS (3)

Signed: fac (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 Le day of Ma a 2025.

EILEEN WILLIAMS PREAS
ic - State of Ariz
MARIGOPAGOUNTY (seal)
Commission # 554349

era PUBLIC My commission expires: II-CI ~ ROD R
ler WiLLLarmA De a9 :

Warrant/Check Number a rot
(if known) (6) DA\ZS . uf 4
Original Date of Issue boa -
(if known) (7) Lt. ZX ). 22
Reason for original issue of Warrant/Check (8): 05/17/2022

Ja Payroll .

C For Services or Goods furnished

C1 Treasurer's refund/payment

Other: