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I Maricopa County Human Resources 2020 JAN 10 NI 1:51 tue\I_Lx Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: January 10, 2020 Re: Replacement of Lost Payroll Warrants Please find attached I 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. 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 1 02/25/2015 Signed: warrant/chedi be ,issupd to him/h r in the sum of $ G50 ,00 (4) EILEEN WILLIAMS-PREAS Notary Pubk - State °Minna MARICOPA COUNTY Commission #854349 Expires November a, 2922 A.R.S. 11-632 & 11-644 ALA ir Ke. DATE 101-0 011/1 411, 11% • Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: D Duplicate or 1:1 Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA 5e,Oel w rAtiatoe,k—( Name/C aimant On or about (a ( 2-0 ) q (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 Not" 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 ID day of 20 20 . JJJJYW ?1.1-1-fAk.A0 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: .(3) NOTARY PUBLIC My commission expires: I - Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) .P2(059C06 7 (.0(24,9 aol Reason for original issue of Warrant/Check ( ISI4ayroll Li For Services or Goods furnished LI Treasurer's refund/payment Li Other: C:\users\williamse\AppData\Local\Microsoft\windows\Temporary Internet Files\Content.Outlook\HTTDL74G \Warrants Checks notice of claim.doc Revised April 2015 tA, CL. 5 Ct.. k\oe_ Ql,te&K.