STAMPED & REDACTED CHRISTOPHER COLGAN.PDF

eM MARICORR COULTS Maricopa County
Human Resources
eb2) sant 194 APR an 8D 20 ANI: a4 12 Paes
VMemo
To: Cindy Goelz, Clerk of the Board
From: Monica Reyes
Date: April 20, 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
Affidavit /Claim Form Couns
TY oupticate
This application is for: or LI 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.
KES76 ‘ (1), being first sworn, upon oath deposes and says:
ame/Claimant
On or about [7 A@cL Zo2! (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
G
ne issued to him/her in the sum of $ [44 |. I4 {3)
EE EZ
Fz
Signed: (4)
#
Note, Please sttach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this ZO __day of AD 202 .
NOTARY PUBLIC
%, EILEEN WILLIAMS-PREAS
Public - State of Arizona
My commission expires: MARICOPA COUNTY
\W- A-Doae Expires November 9, 2022 (seal)
~
Warrant/Check Number
. L30 5524
known) (6)
Original Date of Issue
IY Ach. 202.1
(if known) (7)
Reason for original issue of Warrant/Check (8):
[4 Payroll
1 For Services or Goods furnished
04/20/2021
LC) Treasurer's refund/payment -
(11 Other:
C:\Users\williamse\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.UUTIOOK\H | | UL/4G\warrants Unecks nouce
of claim.doc
Revised April 2015 A.R.S. 11-632 & 11-644

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: Colgan, Christopher J Company: MC1 Off Cycle: N
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Pay Group: ‘NEX Separate Check # 0
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“Colgan, Christopher J- MICIINEX
a Paycheck View ( MCY-Eamings- | Taxes” Gane [< Garnishments = Goan a Distributions
Name Colgan,Christopher J Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23053329 04/14/2021 1,819.32 310.87 64.31 1,444.14
~ Regularand Overtime Earnings me of Taxes
RegHours —_ Reg Pay OT Hours OT Pay mel FED SSDisMLVEE 108.81
FED MedicareEE 25.45
FED Withholdng 145.02
40.00 891.20
* FED SS/Dis ER 108.81
40.00 891.20
m= | * FED MedicareER 25.45
~ OtherEarnings = - Deductions
Code Hours Amounts Add to Gross} j—4 43P Before-Tax 54.85
AWP' 1.50 33.42 Y & 50 Before-Tax 0.66
SH1 7.00 3.50 Y iS 61 Before-Tax 8.80
-| | * 43PER Nontaxable 271.35
* 50ER Nontaxable 2.74
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ADP Enterprise HR screen print as of: 04/19/2021 11:30 AM