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Maricopa County Human Resources Vemo To: Cindy Goelz, Clerk of the Board From: Lisa Platek Date: January 15, 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 Lisa P at ext. 63619 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant “Cel — Thank you. Replacement Lost Warrant Form 1 02/25/2015 Maricopa County Human Resoutces Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix,AZ 85003-2148 DATE: January 14. 2021 Phone: 602-506-3519 Payroll Fax: 602-372-0277 Records 602-506-5509 TO: Eileen Williams/ Lisa Platek Pax: “meeww—= FROM: _ Lisa Platek RE: Stop Payment on Warrant Please place a stop payment on the Warrant listed below. It has been determined that the Warrant is outstanding as of this date: Warrant Number: 0023040180 Issue Date: 12/23/2020 Payable to: Keith E Hoover Jr. Amount: 1,032.43 Reason for Stop Payment: never received Attach a print screen of the paycheck view. CIO Authorized Signature — Payroll Specialist _| Ab 20 Dstopped Li“ ttf a Date Stopped by DSvly ly FE, Time Ya) 42a le Transaction Number Stopped Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/ Claim Form This application is for: [=] Duplicate or L] Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numt ers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. Keith E Hoover Jr. (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/23/2020 (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 to in the sum of $ 1,032.43 ‘(3) 7h an Mh [; 6 Signed: Z é (4) _, Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. h (5) Subscribed and sworn to before me this ‘% day of Janu ary 202/ . IO DD NOTARY PUBLIC My commission expires: 4-05- 202! (seal) Meraneiaow(@) [0023040180 Original Date of issue | 12/23/2020 Reason for original issue of Warrant/Check (8): Payroll C1 For Services or Goods furnished 01/15/2021 ' LJ Treasurer’s refund/payment LC) Other: Revised April 2015 A.R.S. 11-632 & 11-644 ( Paycheck View | WV _ Name Hoover Jr,KeithE Confirmed Check : | | Checkd 2 Issue Date Earnings Taxes Deductions Net Pay = 23040180 12/23/2020 1,335.00 — 139.44 163.13 1,032.43 2 : __Regularand Overtime Earnings mp Taxes RegHours a RegPay OTHours _—OT Pay = ‘FED SSDisMLVEE 82.77 - = = : FED MedicareEE -19.36| 7 nn FED Withholdng 22.04 = * FED SS/Dis ER 82.77 7 FED _MedicareER — 19.36 | = ; - OtherEarnings — : = - Deductions = = = _ : Code Hours Amounts Add to Gross; }-—= 14 After-Tax == 2 AO OTP | 3.00 135.00 Y 12 Before-Tax | 16073 = : * 42 Nontaxable 160.73 | = Nontaxable 2.40 ADP Enterprise HR screen print as of: 01/04/2021 12:32 PM ie A