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2020 FEB 14 Hi 2: 21 Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: February 14, 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 Debbie U. at ext. 66329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form Duplicate Warrant ) ,/ Mtk.l-4--r-c c.--V,otn 1 02/25/2015 My commission expires: (5) Subscribed and sworn to before me this 4 day of il-elorup,s-ti 20 NOTARY TIFFANY PARKERSON Notary Public - State of Arizona MARICOPA COUNTY My Commission Expires May 18, 2021 (seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) 4,9'g7/ 7 ;2- - 5 ,20 aso Reason or original issue of Warrant/Check (8): Payroll O For Services or Goods furnished O Treasurer's refund/payment O Other: EB t8 2020 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 COUNTY OF MARICOPA &—reqv y /4. //Cc /06-K (1), being first sworn, upon oath deposes and says: Nam&Ciainia t On or about — a0 (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/checls be issued to him/her in the sum of $ I -30(0 ` .(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. Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. C: \Users\williamse\AppData \Local \Microsoft \Windows\Temporary Internet Files\Content.Outlook\HTTDL74G \Warrants Checks notice of claim.doc Revised April 2015 A.R.S. 11-632 & 11-644 CT,