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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Tiffany Parkerson 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 Tiffany at ext. 6-2406 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/2512015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: =I Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA fJç rrcf( 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 /- (clate)(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/check be issued to him/her in the sum of $ 5Z5, O5 .(3) Signed: ttr1,1A e4A— (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 2-R day of -3aAuz-_,Arcl 20 NOTA UBLI My commission expires: .1 7 1 Warrant/Check Number (if known) (6) ,D C0 ciL2G- Co Original Date of Issue (if known) (7) /000 TIFFANY PARKERSON Notary Public- State of Arizona MARICOPA COUNTY My Commission Expires May 18, 2021 (seal) Reason for original issue of Warrant/Check (8): E/ Payroll For Services or Goods furnished El Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Scott,Darrell L MC1 - Maricopa County 7054 - Planning and Asset Mgt NEX- Non Exempt Active 08/19/2013 Company: MCI Pay Group: NEX Period End 01/12/2020 Page 1201 Line: Off Cycle: N Separate Check # 0 Reprint . N Adjustment: N Distributions Confirmed • .:.1Ssu 01/22 Check/Advice .:Checkt 22696586 Name Scott,Darrell L Issue Check Transit#: Earnings 1,454.40 Check and Advice Amount 350.00 ADP Enterprise HR screen print as of: 01/28/2020 09:43 AM