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Maricopa County Human Resources Vemo To: Juanita Garza, Clerk of the Board From: Monica Reyes Date: January 13, 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___ Monica at x 6-8051_ for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) Duplicate Warrant Thank you. loud Dolnd - Aye RECEIVED JAN 96 2022 MARC U2. COUNTY GLERK BOARD OF < UPERVISORS Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or Cd 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. Cary Bailen (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 1/9/2022 (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 ¢/18.67 (3) Signed: Qu ff — (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 \2 day of Saw 202022) NOTARY PUBLIC @ EILEEN WILLIAMS-P| Dy Y, Nolay Puble- ia crane MARICOPA COUNTY . . Commission # 554349 My commission expires: Expires November 9, 2022 WG -aoaa (seal) Warrant/Check Number (it known) (6) 23103689 Original Date of Issue (if known) (7) 1 /5/2022 Reason for original issue of Warrant/Check (8): ml Payroll 1 For Services or Goods furnished 01/26/2022 CO Treasurer’s refund/payment = 1 Other: Revised April 2015 ARS. 11-632 & 11-644