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Maricopa County Human Resources RECEIVE - irctitiko 'b5 Memo SEP 20 2019 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Fran McCarroll, Clerk of the Board From: Lisa Platek Date: September 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 Lisa . at ext. 63619 for any questions. Please route approved Affidavits back to County Payroll, Suite Stale Dated 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: RI 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. Cassandra St. Clair (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 09/18/2019 (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/che be issued to him/her i .(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 t eo day of el.,ve_wilcier2o1,9 . ta , eb_40_7 NOTAR PUBLIC MEGAN E B1RT Notary Public - Arizona My commission expires: Maricopa County 0(42 /19 /z_z_ Commission # 549718 (seal) , My Commission Expiros June 19, 2022 Warrant/Check (if known) Number (6) 22& 75- I V?) Original Date of Issue 09/18/19 (if known) (7) 2 4 2019 Reason for original issue of Warrant/Check (8): 111 Payroll El For Services or Goods furnished III Treasurer's refund/payment *I Other: Changed direct deposit check sent to old address Revised April 2015 A.R.S. 11-632 & 11-644 811131769 St Clair,Gassandra R - MC1/EXIVI Paycheck View NICY-Earnings Taxes v Deductions Garnishments Special Accumulators Distributions Name St Clair,Cassandra R Confirmed Check Checkt Issue Dats Earnings Taxes Deductions Net Pay 22675163 09/18/2019 1,360.00 174,18 173.97 1,011 85 Check/Advice# Type Account# Amouni Transit#: ADP Enterprise HR screen print as of: 09/19/2019 04:27 PM 811131769 - St Clair,Cassandra iViCi/EXM Paycheck View MC -Earnings Taxes Deductions Garnishments Special Accumulators_ Distributions Name StClair,Cassandra R Confirmed Check Check1 Issue Date Earnings Taxes Deductions Net Pay 22675163 09/18/2019 136000 174.18 173.97 1,011 85 r Regular and Overtime Earnings Reg Hours Reg Pay OT Hours OT Pay SSDisMLvEE 84.32 MedicareEE 19.72 40.00 680.00 VVithhoidng 60.56 24.00 408.00 SS/Dis ER 84.32' FED MedicareER 19.72 Other Earnings Code Hours Amounts Add to Gross After-Tax 9.28 HOL 8.00 136.00 14 After-Tax 2.31 VAC 8.00 136.00 12 Before-Tax 162.38 57 Nontaxable 16.04 90ER Nontaxable 0.54 ADP Enterprise HR screen print as of: 09/19/2019 04:28 PM