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LI OA.h;.) OF Cl.k,'; SUPER tfi'41-:.'S Maricopa County tikate0711', CrW:=IT Y . Human Resources 2013 NOV 19 PH I?: J( Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: November 19, 2019 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: IEJ Duplicate or 0 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. Keegan L. Doolan (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 11/13/2019 (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 him/ber in the sum of $2,541.29 .(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) Subscribed and sworn to before me this I CA day of Kb 20 19 . ' WL.ItAD't, TY\S NOTARY PUBLIC EILEEN W1LLIAMS-PREAS Notary Public - State of Arizona My commission expires: MARICOPA Commission COUNTY #664349 11 -CI -ae%D3- EvIres November 9, 2022 (seal) Warrant/Check Number 22685175 (if known) (6) Original Date of Issue 11/13/2019 (if known) (7) Reason for original issue of Warrant/Check (8): El Payroll • For Services or Goods furnished IN • Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Doolan,Keegan L Company: MCI Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 5041 - District I Period End 11/03/2019 Reprint: N NEX- Non Exempt Page. 580 Adjustment: N Active 10/01/2018 Reg/FT Line: 811130207 - Doolan IKeegan L MCVNEX r Paycheck View MCY-Earnings Taxes rDeductions Garnishments Special Accumulators Distributions Name Doolan,Keegan L Confirmed Check Checkll Issue Dats Earnings Taxes Deductions Net Pay I 22685175 11/13/2019 3,918.24 863.51 513.44 2,541.29 T Regular and Overtime Earnings 7 Taxes Reg Hours Reg Pay OT Hours OT Pay Fal FED SSDisMLvEE 237.40 • FED MedicareEE 55.52 40.00 992.00 • FED Withholdng 526.09 40.00 992.00 * FED SS/Dis ER 237.40 * FED MedicareER 55.52] T Other Earnings r Deductions I Code Hours Amounts Add to Gross 301 After-Tax 7.87 OTP 27.50 1029.52 Y 80 After-Tax 4.52 SH1 16.00 8.00 Y 91A After-Tax 2.08 SH2 32.00 24.00 Y 92 After-Tax 3.77 OTP 22.25 834.53 Y 184 Before-Tax 46.52 ADP Enterprise HR screen print as of: 11/1912019 10:07 AM