STAMPED & REDACTED KEVIN CHATMAN.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board

DEC 06 2021
From: Daniel Villalba (Payroll Specialist) MARICOPA COUNTY

CLERK BOARD OF SUPERVISORS
Date: December 1, 2021

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 Daniel. at ext. 6-2406 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: A Duplicate or CO 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.
f

Kevin © oe AT7IA oS (1), being first sworn, upon oath deposes and says:
~~ Name/Claimant ;

Onor about /Vs/ 24 262] (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/chegk LTT | to him/her i in the sum of $ OA. (ZS (3)

tz ——— (4)

Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

Signed==— =

(5) Subscribed and sworn to before me this__[__day of Bec 202.
PATRI EUECIS EILEEN WILLIAMS-PREAS
NN RICOPRCOUNTY
My comes expires: Commission # 864340,
{-G-21 Expires Novenee”. (seal)
Warrant/Check Number 2NG
(if known) (6) 23094 Tle tf
Original Date of Issue L [
7 (if known) (7) I) ‘ 24 . 24
Reason for original issue of Warrant/Check (8):
Payroll
C For Services or Goods furnished
O Treasurer's refund/payment 12/07/2021

O Other:

Revised April 2015

Management & keversals

Look up the details of a single payment or range of payments by using the form below.
NOTE: The maximum check range is limited to 50 checks per request. :

CHECK SEARCH Beas eesti

Chatman Kevin G # 23094764
$844.25 issued on 1724/2021 check Unpaid/Uncashed