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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Debra Upton —or r>.) Date: July 18, 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: 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. 41_10:i .T.Mno (1), being first sworn, upon oath deposes and says: Name/Claimant I in 1 01 On or about ) I,) I (date)(2) a warrant/check was issued to the above named persban/eniity 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 $ 2_\ 0I .(p5 .(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. to before me this ) gtb day of 3L) 20 I? . NATHAN DAVIDSON NOTARY PUBLIC - ARIZONA My commission expires: Maricopa County Commission #547162 Ilme 1 ; My Commission Expir*e June 1, 202 Warrant/Check Number (if known) (6) 266-2,2 ?9 Original Date of Issue (if known) (7) 7 - /0-19 Reason for original issue of Warrant/Check (8): Payroll LI For Services or Goods furnished LI Treasurer's refund/payment C.!) LI Other: C"--) 0 MINIM • • rri Cfl 01 Revised April 2015 A.R.S. 11-632 & 11-644 - Turino,Julia M Company: MCI Off Cycle: N MC1 - Maricopa County Pay Group: NEX Separate Check # 0 2662 - LBJ Outpatient Medical Period End 06/30/2019 Reprint: N NEX-Non Exempt Page . 385 Adjustment: N Active 06/17/2019 Reg/FT Line: 4 Turino,Julia M - MC1/NEX Paycheck View CY- Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Turino,Julia M Confirmed Check SSDisMLvEE MedicareEE Withholdng SS/Dis ER MedicareER After-Tax Before-Tax Nontaxable Nontaxable ADP Enterprise HR screen print as of: 0711812019 01:49 PM