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Maricopa County Human Resources 2915 AUG 26 PM 3: 07 /270 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: August 26, 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 Debbie U. at ext. 66329 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: lE1 Duplicate or El 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. ,Riel o Clad tAseJ e n (1), being first sworn, upon oath deposes and says: 4a m e/ n On or about (3 /24 izoot (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 issued to hirr)/her in the sum of $ (t0a. St .(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 '2-10 day of li tLft3( a* 20 19 . XLLc NOTARY PUBLIC LESLIE DARRINGTON Notary Public - State of Arizona MARICOPA COUNT), My commission expires: My September Commission 13. Expires 2021 612.13-Vc2i(rtow V3 202A (seal) Warrant/Check Number e32(.70 (57 (if known) (6) Original Date of Issue (if known) (7) APPRovEu Reason for original issue of Warrant/Check (8): AUB 27 2019 Ik Payroll DAT CI For Services or Goods furnished MARICOPA COUNTY Eli Treasurer's refund/payment CI Other: CAUsers\williamse\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\HTML.74G\Warrants Checks notice of Revised claim.doc April 2015 A.R.S. 11-632 & 11-644 - Moses,Airrion K Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 5073 -Training Division Period End 08/11/2019 Reprint: N NEX - Non Exempt Page: 693 Adjustment: N Active 07/29/2019 Reg/FT Line: - Moses,Airrion K - MC1INEX -7- Paycheck '- View MC' Earnings I Taxes Deductions Garnishments SpesialAccumulators Distributions Name Moses,Airrion K Confirmed Check Check i4 • Issue Date Earnings Taxes Deductions Net Pay 22670157 08/21/2019 2,388.40 401.94 183.58 1,802.88 1 - Regular and Overtime Earnings ' n Taxes - - FED MedicareEE 34.63 I I Reg Hours Reg Pay OT Hours OT Pa FED Withholdng 201.19 FED SS/Dis ER 148.08 40.00 777.20 40.00 777.20 FED MedicareER 34.63 AZ Withholdng 18.04 r OtherEarnings n Deductions- TI Code Hours Amounts Add to Gross 147 After-Tax 50.00 AWP 1.75 34,00 Y 18 Before Tax 133.58 UNT 800.00 Y 57 Nontaxable 16.04 90ER Nontaxable 0.62 91ER Nontaxable 0.31 ADP Enterprise HR screen print as of: 08/26/2019 08:48 AM