STAMPED & REDACTED YOLOTZIN AVILA-CRUZ.PDF

To: Cindy Goelz, Clerk of the Board
From: Linda Greinke
Date: April 8, 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 Linda. at ext. 63770 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: (=| 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.
Yolotzin Avila-Cruz (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about January 20, 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 b ¢ ssued to hj /her in the sum of g¢ 255.82 (3)
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Note, Pledse attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed before me this S) day of Pepi. 20.2/ .
CL
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NOTARY PUBLIC/ ow pat la
SEER, CIERA JACKSON
ae, NOTARY PUBLIC - ARIZONA
My commission Expires. | Maricopa County
Commission # 572824
ID DS 20943 My Commission Expires (seal)
October 08, 2028
_.
Warrant/Check Number a ‘
0023043202
(if known) (6)
Original Date of Issue j
(if known) (7) o1[26 [act
Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished
O Treasurer's refund/payment 04/09/2021
[1 Other: -
Revised April 2015

= Avila Cruz,Yolotzin - MC1/NEX
( Paycheck View
Name Avila Cruz, Yolotzin Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23043222 01/20/2021 287.63 31.81 255.82
- Regular and Overtime Earnings r Taxes
FED SSDisMLVEE 17.83
RegHours Reg Pay OTHours —_OT Pay
FED MedicareEE 4.17
FED Withholdng 4.63
49.50 287.63
* FED SS/Dis ER 17.83
* FED MedicareER 4.17
~ OtherEarnings 7 Deductions
Code Hours Amounts Add to Gross
.
ADP Enterprise HR screen print as of: 04/07/2021 03:31 PM
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