STAMPED & REDACTED - FOR AGENDA ATTACHMENT - AMY BROWN.PDF
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Maricopa County Human Resources Memo To: Juanita Garza, Clerk of the Board Hd 81 190 E202 LN y n)) 0 ar\ pase \ oy Puy From: Sonny Villacorta Date: October 18, 2023 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 Sonny at ext. 63756 for any questions. Please route approved Affidavits back to County Payroll, Suite 800. Duplicate vara >) Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check fi oa oun’s Affidavit/ Claim Form This application is for: xl Duplicate or C1 stale-Datea (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. Amy Brown (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 9/13/23 (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 ¢ 62.84 (3) Signed: Amy Brown (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) Subscribed and sworn to before me this _ 0) day of _ Nitdbey 2024. A dbob= Jet — NOTARY PUBLIC “WATHALIE RIVAS My commission expires: OMARICOPA COUNTY g uf 2021 _ cores ren 4, 2087 (seal) Warrant/Check Number (Gf known) (6) 3612303990 Original Date of Issue (if known) (7) 9/13/23 10/20/2023 Reason for original issue of Warrant/Check (8): . Payroll O For Services or Goods furnished C1 Treasurer’s refund/payment OO Other: *298N0e2y f Revised April 2015 oy 130 babes: 11-632 & 11-644 v MAR)COPA COUNTY Date: Human Resources 301 W. Jefferson St., 8" Floor TO: Phoenix, Arizona 85003 Maricopa County Finance Department From: Maricopa County Payroll P: 602.506.3519 F: 602.372.8722 Re: Maricopa.gov Stop Payment on Warrant Please place a stop payment on the Warrant list below. It has been determined that the Warrant is outstanding as of this date: Fund: 766 SOUACALTO [:3]2 Payable to: Kony Bown Amount: ff bt-D4 Legsy Check Warrant Number: Issue Date: Reason for Stop Payment: a Authorized Signature — Payfoll sea SS alist