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Maricopa County Human Resources 2012 DEC 27 AN 10: Memo To: Fran Fran McCarroll, Clerk of the Board From: Tiffany Parkerson Date: December 27, 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 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 02/25/2015 Akk v Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) 22685370 11/13/2019 (5) Subscritled and sworn to before me this day ofTectos.bc,1 20 1/ . TARY PUBLIC My commission xpires: 041/0y2J32 DEC LO 20 Reason for original issue of Warrant/Check (8): III Payroll 7- pi< P - O For Services or Goods furnished Omar Reym Noun, Pubic rooPa County. Ariz°" My comm. Expires 04-07-2023 Commission No. KAM (seal) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: • Duplicate or El Stale-Dated (definitions are on page 2) 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: (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 warrant/check be issued to him/her in the sum of $ 2,249.51 .(3) Signed: (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was origindlly issued. LI Treasurer's refund/payment LI Other: STATE OF ARIZONA COUNTY OF MARICOPA -77-kc1 e_s pa;, Name/Claimlant On or about Revised April 2015 A.R.S. 11-632 & 11-644