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BOER BERR oe Maricopa County Human Resources @28 NOV 23 PM 2: 32 Mand, Memo To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: November 18, 2020 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 220. Stale Dated Warrant Duplicate Warrant Thank you. wo > Replacement Lost Warrant Form 62 ACH 2 02/25/2015 10 i Ha ' Application for a Duplicate or Stale-Dated W Affidavit/Claim Form This application is for: Duplicate or C1] Stale-Dated (definiti STATE OF ARIZONA Note: Numbers on this form correspond to numbers on COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. Zak Ghali ing fi Raat (1), being first sworn, upon oath deposes and say: On or about 10/28/2020 (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 ee in the sum of ¢ 565. te) (3) ZZ Signed: a (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 __! 8 day of _Noverbe 2024, NOTARY PUBLIC PORTIAM. LOMA, woos vee Notary Public - State of Artznn: My ees expires: MARICOPA COUNTY ° “|S -a1 My Conimigsion Expires | (seal) dune 15, 2021 Warrant/Check Number (if known) (6) 23030657 Original Date of I gina (if Frown) o 1 0/28/2020 Reason for original issue of Warrant/Check (8): fm Payroll QO For Services or Goods furnished ‘ C Treasurer's refund/payment 1 Other: Revised Apri