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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: June 15, 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 NOTARY PUBLIC STATE OF ARIZONA MiAcopa County ROI3EiVi SCHENBERG My Commission Expiros March 17, 2022 (seal) 0023007751 4/1/2020 Reason for original issue of Warrant/Check (8): ig Payroll El For Services or Goods furnished ETreasurer's refund/payment 00ther: N 1 ,27 2020 (k44" Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or El 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. (1), being first sworn, upon oath deposes and says: April 1, 2020 On or about (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/ eck be issuedlp hi her in the sum of $ 180.00 .(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 ir day of 20 D-d. Patti L Ford Name/Claimant --TARY PUBLIC My coiniissiin xppsj_ ? Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Revised April 2015 A.R.S. 11-632 & 11-644 M Ford,Patti L opa County 2120 - Election Day Services ELE- Elections Active 03/17/2020 Temp/PT Company: MCI Pay Group: ELE Period End 03/22/2020 Page 2781 Line: 2 Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N - Ford,Patti L MC1/ELE Paycheck View Taxes Deductions Garnishments Distribu MCY- Earnings Special Accumulators ADP Enterprise HR screen print as of: 06115/2020 07:17 AM