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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes 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 Monica at x 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) Thank you. 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. Brent A Martin (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 to him/her in the sum of $ 729 . 70 .(3) (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 2D day of klo N,/ 20 t . dajoso -Pau NOTARY PUBLIC EILEEN VVILLIAMS-PREAS Nciaty Pubo. Stabs of Afton My commission expires: MARICOPA COUNTY 11-ck• DODD, Ex.1:4!!'tloyaniPlt COM111461041 654349 01.2022 (seal) Warrant/Check Number 22685209 (if known) (6) Original Date of Issue 11/13/2019 (if known) (7) Reason for original issue of Warrant/Check (8): It Payroll ri LI For Services or Goods furnished LI Treasurer's refund/payment El Other: A Revised April 2015 V 2 1 2019 A.R.S. 11-632 & 11-644 DATE 4 " , MARICOPA COUNTY Martin,Brent A Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 5073 -Training Division Period End 11/03/2019 Reprint: N NEX-Non Exempt Page 700 Adjustment: N Active 10/2812019 Reg/FT Line: 7 811133636 - Martin,Brent A -MCI IN r Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Martin,Brent A Confirmed Check Checkh Issue Date Earnings Taxes Deductions Net Pay 22685209 11/13/2019 871.19 94.34 47.15 729.70 r Regular and Overtime Earnings I Reg Hours Reg Pay OT Hours OT Pay SSDisMLvEE 54.01 MedicareEE 12.63 Withholdng 5.29 40.00 777.20 SS/Dis ER 54.01 * FED MedicareER 12.63 OtherEarnings -- Deductions Code Hours Amounts Add to Gross 375 After-Tax 5.79 AWP 1.50 29.15 374 Before-Tax 41.36 OTP 1.50 44.09 * 57 Nontaxable 16.04 SH1 41.50 20.75 * 90ER Nontaxable 0.62 * 91ER Nontaxable 0.31 ADP Enterprise HR screen print as of: 11/1912019 04:23 PM