HOYLA.PDF

Maricopa County
Human Resources

RECEIVED “2

Memo sv 1620

MARICOPA COUNTY
GLERK BOARD OF SUPERVISORS

To: Fran McCarroll, Clerk of the Board

From: Lisa Platek
Date: October 16, 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 at ext. 63619 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.

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: Duplicate or C1 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.
Robert B Holya (1), being first sworn, upon oath deposes and says:
~ Name/Claimant
On or about 10/06/2020 (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 issued to him/her in the sum of $3,788.46 (3)

Signed: (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 1S day of Oct 2020.

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS

My commission expires: Public - State of Arizona
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Warrant/Check Number a
(if known) (6) 2301608

Original Date of I:
nate (if rhe oO 1 0/06/2020

Reason for original issue of Warrant/Check (8):
@ Payroll

O For Services or Goods furnished

O Treasurer's refund/payment
O Other:

Revised April 2015 A.R.S. 11-632 & 11-644

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