GAUSE.PDF

Maricopa County 
Human Resources 
Memo 	
RECEIVED. A,AD2.4.6ww 
DEC 2 0 201Y 
MARICOPA COUNTY 
To: 	
Fran McCarroll, Clerk of the Board 	
CLERK BOARD OF SUPERVISORS 
From: 
Zellnor Bullis 
Date: 
December 20, 2019 
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 Zellnor B. at ext. 60409 for any questions. Please 
route approved Affidavits back to County Payroll, Suite 220. 
Stale Dated Warrant 	
Duplicate Warrant 
Thank you. 
Replacement Lost Warrant Form 	
02/25/2015

22688055 
11/27/2019 
I 	
zi% P 
-ED 
DEN 0 2019 
Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: 
1 Duplicate or 0 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. 
Gwen P Gause 
(1), being first sworn, upon oath deposes and says: 
Name/Claimant 
On or about 	
November 27, 2019 	
(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/checkl_el-ssue06-him/yei in t9y<Um of $ 919.07 
Signed: 
/Note: Please attach a clpy of the warrant/check if avallableand/or any other 
'evidence that a warrant//heck was originally issued. 
.(3) 
(4) 
(5) S b ribe• ; nd sworn to before me this  OA'clay of 	
20 	
. 
• 
8.3.11al 
RY /TO BL, 
HOPE  M. OLGUIN 
Notary Public -State of Arizona 
MARICOPA COUNTY 
My Commission EXpiresApriI4,2022 
My om.mi sion expires: 
(seal) 
Warrant/Check Number 
(if known) (6)  
Original Date of Issue 
(if known) (7)  
Reason for original issue of Warrant/Check (8): 
Payroll 
El For Services or Goods furnished 
OTreasurer's refund/payment 
El Other: 
Revised April 2015 
A.R.S. 11-632 & 11-644