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HARICOP-;!, OF SUI, • L Maricopa County Human Resources 2019JUN -3 PM InQ 440-,a 'De\ vA 7emo L 1J q)) 11, Fran McCarroll, Clerk of the Board Fr/0nm Zellnor Bullis Date: May 31, 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 Zellnor13. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 100D2102120ELEC10000 P21047 Dept: 2120— Elections Stale Dated Warran Duplicate Warrant Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 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. Stephanie Robles (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 9/19/2018 (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 $ 195.50 .(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 3"-414- 20 19 . ?du NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Public - State of Arizona My commission expires: MAR1COPA Commission COUNTY I 664349 1 -Ct 2D22— MN. Expires November 9, 2022 (seal) Warrant/Check Number 22603293 (if known) (6) Original Date of Issue 09/19/2018 I•I- (if known) (7) Reason for original issue of Warrant/Check (8): II Payroll 0 For Services or Goods furnished 0 Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-644 11.111111-Robles,Stephanie Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: ELE Separate Check # 0 2120- Election Cycle Period End 09/09/2018 Reprint: N ELE - Elections Page: 2067 Adjustment: N Active 11/08/2016 Temp/PT Line: Robles,Stephanie - MC1/ELE r Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Robles,Stephanie Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 22603293 09/19/2018 195.50 195.50 Regular and Overtime Earnings I Reg Hours Reg Pay OT Hours OT Pay Other Earnings Deductions Code Hours EBT 1.00 EPW 15.50 ADP Enterprise HR screen print as of: 05/30/2019 04:33 PM