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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zell Bullis Date: November 20, 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 Zell B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank RFCEIVED -Ds NOT 2 0 2019 MARICOPA COUNTY Replacem —CLERK-BOARD-OF-SUPERVISORS 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form / This application is for: [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. Fifer, Catherine D (1), being first sworn, upon oath deposes and says: Name/Claimant On or about O October 30, 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, gr 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 $ 78-09 .(3) 4_ Signed: (4) Note: Please attach a cbpy 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 13441 day of Kidatilli7Or 20 [q . evula NOTARY PUBLIC KRISTINE PASSARELLI Notary Public • State of Arizona MARICOPA COUNTY My commission expires: My Commission Expires May 19, 2020 5-1c1 - aA9.0 (seal) •I, Warrant/Check Number 22682615 (if known) (6) Original Date of Issue 10/30/2019 (if known) (7) APPROVED Reason for original issue of Warrant/Check (8): NOV-2 1 2019 el Payroll DATE 0 For Services or Goods furnished 0Treasurer's refund/payment MARICOPA COUNTY 00ther: Revised April 2015 A.R.S. 11-632 & 11-644 - Fifer,Catherine D Company: MCI Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 2130 - Election Services and Tabulati Period End 10/20/2019 Reprint: N NEX- Non Exempt Page. 249 Adjustment: N Active 07/09/2018 Temp/PT Line: 4 811128900 - Fifer,Catherine D - MC1/NEX Name Fifer,Catherine D Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 22682615 10/30/2019 88.00 9.91 78.09 - Regular and Overtime Earnings Taxes I Reg Hours Reg Pay OT Hours OT Pa FED SSDisMLvEE 5.46 FED MedicareEE 1.28 8.00 88.00 FED SS/Dis ER 5.46 * FED MedicareER 1.28 AZ Withholdng 3.17 r Other Earnings Deductions Code Hours Amounts Add to Gross ADP Enterprise HR screen print as of: 11/20/2019 09:22 AM