Extracted text (via pymupdf_layout)
3239 characters
i tc,D Maricopa County Human Resources 2019 JUL 30 FM Memo To: Fran McCarroll, Clerk of the Board 1ECM11: Debbie Upton Den: July 30, 2019 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: 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. Tyler P Elam (1), being first sworn, upon oath deposes and says: Name/Claimant On or about July 14, 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 $ 1,563.49 .(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 sw_ re me this 747 day of JLA, 20 19 . NOTARY PJOBLIC JESUS AYALA NOTARY PUBLIC - ARIZONA MARICOPA COUNTY My Oofrimission expires: My Commission October 7, 2019 Expires "eite19-ti 7 U11 (seal) f Warrant/Check Number 22664964 (if known) (6) Original Date of Issue 7/24/2019 (if known) (7) JUL Reasop for original issue of Warrant/Check (8): CO S I Payroll MARICOPA CARD OF COUNTY SUPERVISORS El For Services or Goods furnished 111 Treasurer's refund/payment CI Other: cri Revised April 2015 A.R.S. 11-632 & 11-644 Elam,TylerP Company: MCI Off Cycle: N MC1 - Maricopa County Pay Group: PRB Separate Check # 0 1130 - Operations Period End 07/14/2019 Reprint: N . 1 PRB-Probation Page . 47 Adjustment: N ' Active 07/01/2019 Reg/FT Line: 4 - Dam,Tyler P - MC1/PRB 1 Paycheck View MY Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Elam,Tyler P Confirmed Check Check li Issue Date Earnings Taxes Deductions Net Pay 22664964 07/24/2019 1,744.00 180.51 1,563.49 - Regular and Overtime Earnings --- - Taxes : Reg Hours Reg Pay OT Hours OT Pa FED SSDisMLvEE 108.13 22.06 480.91 FED MedicareEE 25.29 9.94 216.69 FED SS/Dis ER 108.13 27.58 601.24 FED MedicareER 25.29 12.42 270.76 AZ Withholdng 47.091 7 OtherEarnings r. Deductions ; Code Hours Amounts Add to Gross! HPA 5.52 120.34 Y HPA 2.48 54.06 ADP Enterprise HR screen print as of: 07/30/2019 12:45 PM