BUSTILLOS.PDF

Maricopa County 
Human Resources 
Memo 
To: 	
Fran McCarroll, Clerk of the Board 
RECEIVED„,' s. 
MAY 1 2 2020 
MARICOPA COUNTY 
CLERK BOARD OF SUPERVISORS 
From: 
Monica Reyes 
Date: 
May 12, 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 	
Monica 	
at x 6-8051  for any questions. Please 
route approved Affidavits back to County Payroll, Suite 220. 
Stale Dated Warrant (Over 1 Year) 
Thank you.

NOTARY PUBLIC 
My commission expires: 
11 cLao  
(seal) 
MAHICOPA COUNTY 
Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: 
gpDuplicate or 0 Stale-Dated (definitions are on page 2) 
Note: Numbers on this form correspond to numbers on the 
Instruction sheet which is page 2 of this form. 
eLeCCa 	
BILC-ktikS 	
(1), being first sworn, upon oath deposes and says: 
Name/Claimant 
On or about 	
"11 1 212-02-0 	
(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 
	
.(3) 
(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 	
 
day of 	
20 20  . 
warrant/check be issued to him/her in the sum of $ 
Signed: 
Warrant/Check Number 
(if known) (6)  
• 
3ima41,1— 
Original Date of Issue 
(if known) (7)  
e--1 
Reason for original issue of Warrant/Check (8): 
(,N) Payroll 
0 For Services or Goods furnished 
El Treasurer's refund/payment 	
 
0 Other: 	
 
STATE OF ARIZONA 
COUNTY OF MARICOPA 
Revised April 2015 	
A.R.S. 11-632 & 11-644