SIGNED JOHN MIRAMONTES FOR 021021 AGENDA.PDF

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Maricopa County
Human Resources
2021 JAN -6 Pit 4: 20
Memo
To: Fran McCarroll, Clerk of the Board
From: Monica Reyes
Date: January 6, 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
This application is for: C] 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.
Jon We Mra muvker
oy being first sworn, upon oath deposes and says:
Name/Cilaimant
On or about In [ q/ vo (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
UH . o-
warrant/check be issued to him/her in the sum of $ (3)
Nete/ 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 sworn to before me this 5 day of SOV 2021 .
NOTARY OTARY PUBL PUBLIC
» EILEEN WILLIAMS-PREAS
MARICOPA COUNTY
My commission expires: Commission € 554349
4 -3B0ag Expires November 9, 2022 (seal)
Warrant/Check Number 2301727
(if known) (6)
Original g Date of Issue 12/09/2020
01/11/2021
“if rnown) (7)
Reason for original issue of Warrant/Check (8):
Payroll
O For Services or Goods furnished
[1 Treasurer's refund/payment
C) Other:
Revised April 2015 ARS, 11-632 & 11-644

( Paycheck View
Name Miramontes, John M Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
2301727 12/09/2020 ee
ADP Enterprise HR screen print as of: 01/05/2021 11:37 AM