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Ss i ne yy OF 8 at en's Maricopa County BORE ae 29 NCOP MT Y Human Resources 2021 JAN 20 PM 4: 06 Vemo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: January 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 , Application for a Duplicate or Stale-Dated Warrant/Check , s Affidavit/ Claim Form This application is for: [| Duplicate or L] 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. Francisco Borrero (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/23/2020 (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 800.60 warrant/check be issued to him/her i of $ (3) 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) sworn to before me this ld is day of UGA 202/_. OE NOTARY PUBLIC (ADALI ZAVALETA My commission expires: Expires Auguat 29, 2024 ad 2g 2QY (seal) Warrant/Check Number Original riginal Date of I Date of Issue | 49/23/2020 Reason for original issue of Warrant/Check (8): Payroll 01/22/2021 : O For Services or Goods furnished 1 Treasurer's refund/payment 1 Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Borrero,Francisco L Company: MC1 Off Cycle: N MC‘ - Maricopa County PayGroup: ELE Separate Check # 0 2120 - Election Day Services Period End 12/13/2020 Reprint: N ELE -Elections Page. 239 Adjustment: N Active 11/03/2020. Temp/PT Line: 7 ( Paycheck View Name Borrero,Francisco L Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23040096 12/23/2020 950.17 149.57 800.60 ~ Regular and Overtime Earnings ~ Taxes FED SSDisMLVEE 121.22 RegHours Reg Pay OTHours —_OT Pay — | FED MedicareEE 28.35 * FED SS/Dis ER 424.22 * FED MedicareER 28.35 - OtherEarnings » Deductions Code Hours Amounts Add to Gross ELT 1955.17 N EPT 73.09 950.17 Y ADP Enterprise HR screen print as of: 01/20/2021 12:49 PM