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Maricopa County Human Resources Memo RECEIVED To: Juanita Garza, Clerk of the Board AUG 11 2021 MARICOPA COUNTY From: Daniel Villalba OLERK BOARD OF SUPERVISORS oul, Po Date: August 11, 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 x 6-6329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) [ Duplicate Warrant | Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: O Duplicate or C1 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. Jere L Wi thems (1), being first sworn, upon oath deposes and says: Name/Claimant On or about _AMuyvst (4h 2024 (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 $ | ; | Lhe. 43 (3) Signed: - tained C——— (4) Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) $ ssribedyand sworn to before me this ae day of August 20 A . NOTARY-PUBLIC. BELEN OLVERA : Notary Public - Arizona he TTS expires: Maricopa oo ission V1 1202-4 My aan. Expires 05-17-2024 (seal) Warrant/Check Number ; , (if known) (6) 0023 0n)350 Original Date of Issue (if known) (7) 0g} oY | 202] eason for original issue of Warrant/Check (8): Payroll O For Services or Goods furnished 08/11/2021 O Treasurer's refund/payment j O Other: Revised April 2015