STAMPED & REDACTED JOSHUA GATERS.PDF

Maricopa County
Human Resources
To: Cindy Goelz, Clerk of the Board
From: Daniel Villalba
Date: April 28, 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 ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

;
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: bam Duplicate or CJ stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
Instruction sheet which is page 2 of this form.
COUNTY OF MARICOPA
Joshua Gaiters (1), being first sworn, upon oath deposes and says:
Nameé/Claimant
On or about 93/17/2021 (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 to him/her in the sum of $941 64 (3)
L
Signed: (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 swarn to before me this LE D day of Fart! 221.
} 7
NOTARY PUBLIC
My commission expires:
CL [2029
Warrant/Check Num ber
23049917
check Wu
Original 1g Date of I (03/17/2021
eimoan)
Reason for original issue of Warrant/Check (8):
04/30/2021
Payroll |
C1 For Services or Goods furnished
1 Treasurer’s refund/payment
C] Other:
Revised April 2015 A.R,S. 11-632 & 11-644

( Paycheck View
Name Gaters, Joshua B Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay
23049917 03/17/2021 1,360.00 181.40 236.96 941.64
~ Regular and Overtime Earnings r Taxes
FED SSDisMLVEE 83.37
RegHours _Reg Pay OT Hours OT Pay
FED MedicareEE 19.50
640.00 FED Withholdng 69.52
in00
* FED SS/Dis ER 83.37
40.00 460.00
* FED MedicareER 19.50
- OtherEarnings r Deductions
Code Hours Amounts —_ Add to Gross 91A After-Tax 0.34
_
HP4 15.00 60.00 Y 14 After-Tax 2.45
HP4 5.00 20.00 Y 100 Before-Tax 55.00
SCK 10.00 160.00 Y 44 Before-Tax 42.40
VAC 20.00 320.00 Y 50 Before-Tax 0.66
ADP Enterprise HR screen print as of: 04/28/2021 03:58 PM