STAMPED & REDACTED - MICHAEL OLSON.PDF

Maricopa County
Human Resources

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: January 12, 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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant Duplicate Warrant

Thank you.

ao

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: Xl Duplicate or C 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.
Michael Olson (1), being first sworn, updn oath deposes and says:
Name/Claimant

On or about _ 12/21/22 (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 $ 507.19 (3)

Signed: Mmd < Dern (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) Su mae to before me this qt day of Ganuary 2023,

NOTARY PuBLfC \__)

My A AS) expires:

RENEE M HERNANDEZ
Notary Public
Commission Number 633037
Expires: August 20, 2026
Maricopa County

(seal)

Warrant/Check Number

(if known) (6) 3012303389

Original Date of Issue
(if known) (7) 1 2/2 1 /22

Reason for original issue of Warrant/Check (8):
OO Payroll

C1 For Services or Goods furnished
OO Treasurer’s refund/payment
mm Other:

1/12/2023

Revised April 2015

Maricopa County 301 W, Jefferson St. Suite 800 Phoenix, AZ 85003

-507.19 1,014.38)

Se |
Description Dates Rate Amount YTD Hours YTD Amount| |Description Amount YTD
IPS/CORP Contrib F te) 0 554.32] [Federal Withholding 32.16
State Tax - AZ 14.97)
Eamings 0.00 554.32] | Employee Taxes 0.00 47.13

Description Amount YTD}
Replacement Check. -§07.19 507.19}
Post Tax Deductions -507.19 -507.19)

Description

Federal Withholding - Taxable Wages 0.00 584.32!
[State Tax Taxable Wages - AZ 0.00 554.32
See = : 252 = Federal ese

Marital Status Single or Married filing separately!

{Allowances it}

[Additional Withholding Oj

3 oe z. = eS
[Bank Account Name Account Number USD Amount Amount
(Check) 507.19 USD.