STAMPED & REDACTED ANA LOPEZ.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board
From: Daniel Villalba (Payroll Specialist)
Date: September 29, 2021

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 Daniel. at ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.

Stale Dated Warrant

Thank you. eee

Duplicate Warrant

Replacement Lost Warrant Form 1 02/25/2015

AFFIDAVIT/NOTICE OF CLAIM

10/01/2021

STATE OF ARIZONA

COUNTY OF MARICOPA

As 11.) Loa BEING FIRST DULY SWORN

OATH, DEPOSES AND SAYS:

That on the fe day of D0 Qa Inhbwr ,202-|_, he/she presented

to Maricopa County, for payment a claim for services rendered or supplies furnished during the

month of utguuat- , said claim being in the sum of
thlo-Ppoutondl nin wy YAACC. Aacl $04 Ly Put Cears
Dollars ($ >! G3. 4G 2) ) in payment of which the Board of Supervisors caused the

Warrant No. DAQD DY _ to be issued on Zlu/> / ,20 Q-/ _, drawn on the

Payroll Clearing Account fund.

Affiant further says that although he/she was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost. Under penalty of
perjury, affiant hereby affirms that this claim is correct and the amount shown is due and owing.

WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said

Warrant No. _2./) 20U 3) Inthe sum of $§ QDI9OA YD

Dated: a) OY ,20-] Signed: 7

Affiant O
***A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the
replacement check.***

Subscribed and sworn to before me this [ day of Se (Ca 20 21s
“a> awe

syne
Sieh. No. Org

6
Nbtary Public 3° =
My commission expires: Dee. JO DOP | 44 5 ws
“On icopn c eS
ato
UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO:
Name(L Ltr) Ltarry Telephone Number:
7
Address: Employee ID #:
Address:

01/31/2013