STAMPED & REDACTED MICHAEL OROZCO.PDF

Maricopa County
Human Resources
VMemo
To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: May 27, 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 __ Monica at x 6-8051__ 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 : > any
Affidavit/ Claim Form
This application is for: Duplicate or [J 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 Orozco (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 4/28/2021 (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 ¢ 952.18 (3)
Ylyphatk
Signed: Onoyeg- (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) sworn, to before me this _& ly day of MON, 20 |
UL
NOTARY
pyeuc pera F
Greget\ Maricopa County :
My issign expires: ANS A5 5
cpm rit tie Ji ecmemrcas aa <
Wierd (seal)
———
Number 230 SSI ay
Cif known) (6)
Original Date of Issue
uf [28 Z|
Cif known) (7)
Reason for original 9 issue of Warrant/Check ®) (8):
06/02/2021
Payroll
C) For Services or Goods furnished
(1 Treasurer’s refund/payment
CO Other:
Revised April 2015 A.R.S, 11-632 & 11-644

( Paycheck View
Name Orozco,Michael Confirmed Check
Checkd Issue Date Earnings Taxes Deductions Net Pay
23055198 04/28/2021 1,304.00 192.47 159.35 952.18
~ Regular and Overtime Earnings ~ Taxes
FED SSDisMLVEE 80.85
RegHours Reg Pay OT Hours OT Pay
FED MedicareEE 18.91
FED Withholdng 72.06
40.00 640.00
* FED $S/Dis ER 80.85
40.00 640.00
* FED MedicareER 18.91
- OtherEarnings - Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.35
_
OTP 0.25 6.00 Y 12 Before-Tax 157.00
OTP 0.75 18.00 Y * 37 Nontaxable 16.04
* 90ER Nontaxable 0.51
* 91ER Nontaxable 0.26
ADP Enterprise HR screen print as of: 05/27/2021 08:17 AM