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MO JAN 23 00 Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: January 28, 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 02/25/2015 WalkCt_ 1,1\73- NOTARY PUBLIC My commission expires: - - -o tedal) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: El/Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA rOil GY ci tA OWCO\n ame Claimant Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. (1), being first sworn, upon oath deposes and says: On or about 11221AZ-6 (date)(2) a warrant/ 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 $ L1-$'61 , 3 Signed: yy6YISSev j 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 2-(6 day of J 'AAA- 20 20 . .(3) (4) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) 24,06, q3 4/ //;-a-lA024 1 es , L,„„ A 2 9 _2U Reason for original issue of Warrant/Check (8): 12/Payroll LI For Services or Goods furnished CI Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-644 Reg ular and Overtime Earnings ------ Reg Hours Reg Pay OT Hours SSDisMLvEE MedicareEE SS/Dis ER MedicareER Withholdng Bronson,Tamara L MCI - Maricopa County 5072 - Records Id Division Warrants NEX- Non Exempt Active 01/06/2020 Reg/FT Company: MCI Pay Group: NEX Period End 01/12/2020 Page: 679 Line: Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N Name Bronson,Tamara L ADP Enterprise HR screen print as of: 01/28/2020 03:54 PM 511,0 c;ir 7.„7,