Extracted text (via pymupdf_layout)
3062 characters
km) hf3 0.6D-D Maricopa County Human Resources 11/mcaa r-. To: Fran McCarroll, Clerk of the Board From: Lisa Platek Date: June 24, 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 P at ext. 63619 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: C) 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 MAR ICOPA Instruction sheet which is page 2 of this form. Maria)! Cortez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 6/3/19 (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. Therefo,rerunder penalty of perjury, claimant hereby affirms that this claim is correct and tW amount shown is_rtue and owing, and the applicant requests that a replacement /her in the sum of $ 6,010.89 .(3) (4) : PleasV-ittacba co)rly of the warrant/check if available and/or any other etTdence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this PL) day of 20 19 . NOTARY PUBLIC LESLIE DARRINGTON Notary Po* - State dArizone My commission expires: MARICOPA COUNTY Coi 20.t (9 My September Commission 13, Expires 2021 (seal) Warrant/Check Number 3012300794 (if known) (6) Original Date of Issue 6/3/2019 (if known) (7) Reason for original issue of Warrant/Check (8): lk Payroll A • 7. IP Cf,) TIF • JUN 25 2019 El For Services or Goods furnished El Treasurer's refund/payment CI Other: Revised April 2015 A.R.S. 11-632 8t. 11-644 EMI Cortez,Marisol MC1/EXM / Paycheck View MCY- Earnings Taxes Deductions Garnishments / Special Accumulators Distributions Name Cortez,Marisol Confirmed Check Check 4 Issue Date Earnings Taxes Deductions Net Pay 2300794 06/03/2019 8,759.49 2,489.63 258.97 6,010.89 - Reg ularand Overtime Earnings r Taxes Reg Hours Reg Pay OT Hours OT Pa FED SSDisMLvEE 543.14 FED MedicareEE 127.03 FED Withholdng 1,665.51 FED SS/Dis ER 543,14 FED MedicareER 127.03 - Other Earnings Deductions Code Hours Amounts Add to Gross 103 After-Tax 50.00 AWP 40.00 1347.20 Y 14 After-Tax 1 2.16 LVN 220.08 7412.29 Y 100 Before-Tax 50.00 HOL 8.00 269.44 Y 12 Before-Tax 156.81 HPA -8.00 -269.44 12 Nontaxable 156.81 ADP Enterprise HR screen print as of: 06/24/2019 10:24 AM