Extracted text (via pymupdf_layout)
3278 characters
Maricopa County 2013 JUN _ 1 2: 30 Human Resources arAD Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: June 21, 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 Monica at x 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) ( Duplicate Warrant Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: [3/Duplicate or 0 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. I rot ty (1), being first sworn, upon oath deposes and says: Name/C41aimant Lic-J On or about ‘-/2-/q (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 hirri/her in the sum of $ ///k5:- 7 .(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) SubscObed and sworn to befor me this -.2.,U"-Iday of 20 NOTA • PU L C AMY GUTIERREZ My commissipn expires: Notary Public - State of Arizona j 01 01111202- \ My MARICOPA Commission COUNTY Expires (seal) October 8, 2021 Warrant/Check Number (if known) (6) 'o Z2-6 C6f 7/ Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): R"Payroll El For Services or Goods furnished Treasurer's refund/payment 111 Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Haggard,Tracy R Company: MCI Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 5028- Pre-Employment Services Period End 06/02/2019 Reprint: N NEX-Non Exempt Page 572 Adjustment: N Active 05/20/2019 Reg/PT Line: 811050396 - Haggard,Tracy R - MC1/NEX r Paycheck View MCY- Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Haggard,Tracy R Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 22656971 06/12/2019 1,763.86 272.21 305.68 1,185.97 Reg ular and Overtime Earnings Taxes 1 Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLvEE 105.30 FED MedicareEE 24.631 33.75 804.94 FED Withholdng 115.40 31.75 757.24 * FED SS/Dis ER 105.301 * FED MedicareER 24.631 Other Earnings Code Hours Amounts Add to Gross! 81 After-Tax 5.12 SH1 10.50 5.25 92 After-Tax 26.98 HPA 8.00 190.80 14 After-Tax 2.82 SH1 11.25 5.63 43P Before-Tax 52.84 50 Before-Tax 0.66 1 ADP Enterprise HR screen print as of: 06/20/2019 04:30 PM