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50ARD OF CLERK SUPERVISOR'', Maricopa County tiAPIICOP A COOff Human Resources 2019 JUL -3 FH 2:00 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: July 3, 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 02125/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or D 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. Caleb D Gutierrez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 06/12/2019 (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 $ 458.91 .(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 3 day of 2019 . laPaCtifIVQ. NOTARY PUBLIC EILEEN WILL1AMS-PREAS Notary Public - State of Arizona My commission expires: MARICOPA Commission COUNTY # 554349 I Ci • 00,4(-1. Expires November 9, 2022 (seal) Warrant/Check Number 22656882 (if known) (6) Original Date of Issue 06/12/2019 (if known) (7) JUL 5-2019 Reason for original issue of Warrant/Check (8): El Payroll 0 For Services or Goods furnished 0 Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-644 -Gutierrez,Caleb D Company: Mel Off Cycle: N MCI - Maricopa County Pay Group: INT Separate Check # 0 8012 - Law Library Self Service Cntr Period End 06/02/2019 Reprint: N INT- Interns Page. 3 Adjustment: N Active 05/02/2019 Temp/FT Line: 2 - Gutierrez,Caleb D - MC1/INT (-Paycheck View CY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Gutierrez,Caleb D Confirmed Check Checkt Issue Date Earnings Taxes Deductions 22656882 06/12/2019 525.00 66.09 Regular and Overtime Earnings Reg Hours Reg Pay OT Hours SSDisMLvEE 32.55 MedicareEE 7.61 Withholdng 21.73 SS/Dis ER 32.55 MedicareER 7.61 OtherEarnings- Deductions - . Code Hours Amounts Add to Grossl STI 525.00 ADP Enterprise HR screen print as of: 07103/2019 01:21 PM