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Maricopa County Mg JUN 20 f> 1: 52 Human Resources Memo Vox, Fran McCarroll, Clerk of the Board From: Lisa Platek Date: June 19, 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 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: I 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. Clint L Miles (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 6/12/2019 (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 $ 2311.16 .(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 Iq day of Jum_x_ 20 1t.54,..ioakanv) NOTARY PUBLIC EILEEN WILLIAMS-PFtEAS Notary Public- State olArtitone MARICOPA COUNTY My commission expires: Cornmleakm # 554349 ItA• 202:/— Expires November 9, 2022 seal) Warrant/Check Number m6ugi-f6- (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): I Payroll El For Services or Goods furnished El Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644 11111111kiles,Clint L ItfiC1/EXM Paycheck View CY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions • Name Miles,Clint L Confirmed Check Checkil • Issue Date Earnings Taxes Deductions Net Pay 1 22656845 06112/2019 3,309.60 441.95 556.49 2,311.16 i r Regularand Overtime Earnings , Taxes Reg Hours Reg Pay OT,Hours OT Pa ' FED SSDisMLyEE 196.84 FED MedicareEE 46.04 40.00 1654.80 FED Withholdng 148.88 32.00 1323.84 FED SS/Dis ER 196.84 FED MedicareER 46.04 - Other Earnings Deductions Code Hours Amounts Add to Gross 81 After-Tax 11.83 Ala. HOL 8.00 330.96 Y 91B After-Tax 4.57 92 After-Tax 10.01 98A After-Tax 2.30 98B After-Tax 1.00 ,.... ADP Enterprise HR screen print as of: 06/19/2019 10:51 AM