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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board RECEIVED---',"ckNi\iined FEB 20 MO MARICOPA COUNTY CLERK BOARD OF SUPERVISORS From: Linda Greinke Date: February 13, 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 Linda G. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 02/25/2015 um of $ 831.19 DATE FEB Z, 4 2020 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: L1 Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. Karina Tapia (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 02/04/2020 (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 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 V.CVLtar t 20 2-0. INrcbfkiklut Shu-e.r NOTARY PUBLIC DOMINIQUE STIVER BABCOCK Near/ Pubic- Stale °Minns MARICOPA COUNTY (seal) My Commission Expires September 11, 2020 .(3) (4) Warrant/Check Number (if known) (6) 022698669 Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): Payroll 0 For Services or Goods furnished LI Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644