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Maricopa County Human Resources Vviemo To: Fran McCarroll, Clerk of the Board From: Zell Bullis Date: January 26, 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 Zell Bullis 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 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. Shawn Glenn (1), being first sworn, upon oath deposes and says: Name/Claymant On or about November 25, 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 warrant/check be issued to him/her in the sum of $ 36.00 (3) Signed: Bear (loan (4) Note; Please attach a copy of the warrant/check if available and/or any other _ evidence evidence that that 4 warrant/check was originally issued. a VO da day y of. 20.10. (5) ndsworn Shire aire re ae NOTARY ‘me KELLY RAE PORTER Corsa 2) Notary Public - Sis of ives tener 3) A COUN My com ion expires: Commission # 556678 IZQNNSIZ07 2H QTE” —_Expires Deoomber 15, 2022 (seal) Warrant/Check Number 23034479 (if known) (6) Original 9 Date of Issue November 25, 2020 (if known) (7) Reason for original issue of Warrant/Check (8): [V] Payroll (ror Services or Goods furnished / 01/27/2024 L_Ttreasurer’s refund/payment other: Revised April 2015 A.R.S. 11-632 & 11-644 m - Gienn,Shawn i Company: MC1 Off Cycle: N McC1 - Maricopa County | Pay Group: ELE Separate Check # O 2120 - Election Day Services Period End 11/15/2020 Reprint: N ELE-Elections | Page: 2427 Adjustment: N Active 41/03/2020 Temp/PT | Line: 7 i” Paycheck View Name Glenn,Shawn ; Confirmed Check Check# issue Date Earnings Taxes Deductions Net Pay 23034479 11/25/2020 36.00 36.00 ~~ Regularand Overtime Earnings ~ Taxes RegHours Reg Pay OT Hours OT Pay — : —- OtherEarnings (- Deductions ‘Code Hours Amounts Add to Gross _. EPVW 3.00 36.00 Y ADP Enterprise HR screen print as of: 01/26/2021 08:12 AM