STAMPED & REDACTED FERRYN FLOYD.PDF
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ARICO Maricopa County Human Resources eb2i CCT 21 PH &:34 ond Delving be Memo To: Cindy Goelz, Clerk of the Board From: Zell Bullis Date: October 21, 2021 Re: Replacement of Lost Payroll Warrants Please find attached _1 _ Affidavit/Notice of Claim(s) for lost payroll warrants for inglusion 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 Zell Bullis at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 400. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 04/08/2021 ‘ Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: fl Duplicate or CI Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. Ferryn Floyd (4), being first sworn, upon oath deposes and says: Name/Claimant On or about 09/29/2021 (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 $ 1038.21 (3) Signed: ah (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally isstied. y, (5) Subscribed = = to before me this_ 2c) _ day of Coldoey 2021. : a LAr BURGOS = = Ate ZOEL BUR NOTARY PUBEEC XQ Yee) _Nolary Public - Arizona im MARICOPA COUNTY Commission # 698180 My commission expires: y p Expires January 28, 2026, aS ‘Fo 1-28-2025 | Warrant/Check Number 23082822 (if known) (6) Original D f I: rigs (if ote) o 09/29/2021 Reason for original issue of Warrant/Check (8): Payroll 1 For Services or Goods furnished, (1 Treasurer's refund/payment_ 10/26/2021 1 Other: : 7 Revised April 2015 ADP Enterprise HR screen print as of: 10/18/2021 03:11 PM