TORRES.PDF

Maricopa County
I , Human Resources
2019 JUN -5 PN 2:
Memo
To: Fran McCarroll, Clerk of the Board
From: Monica Reyes
Date: June 6, 2019
Re: Replacement of Lost PayroltWarrants
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) r Duplicate Warrant
Thank you.

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.
\)L-tti T-Ortc-e-S (1), being first sworn, upon oath deposes and says:
N me/Claimant
On or about 512gt ig (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/c issued to him/her in the sum of $
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 5 day of Jwyte 20 19 .
qats,at.502tka
NOTARY PUBLIC EILEEN WILLIAMS-PREAS
Notary Public- State of Arizona
MARICOPA COUNTY
My commission expires: Commission #554349
Expires November 9, 2022 (seal)
Warrant/Check Number
(if known) (6)
Original Date of Issue 5t2e/ APP R E
(if known) (7)
Reason for original issue of Warrant/Check (8):
).Payroll
CLERK, BOARD OF SUPERVISORS
• For Services or Goods furnished MAR ICOPA COUNTY
▪ Treasurer's refund/payment
LI Other:
Revised April 2015 A.R.S. 11-632 St 11-644

- Torres,Yvette Company: MCI Off Cycle: N
MCI - Maricopa County Pay Group: NEX Separate Check # 0
8627 - Std Services Period End 05/19/2019 Reprint: N
NEX- Non Exempt Page 1365 Adjustment: N
Active 04/22/2019 Reg/FT Line: 5
Torres lYvette - MCl/NEX
MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions
Name Torres,Yvette Confirmed Check
Checkti Issue Date Earnings Taxes Deductions Net Pay
22654550 05/29/2019 1,096.00 173.72 173.75 748.53 1
- Regular and Overtime Earnings
Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLvEE 65.20
FED MedicareEE 15.25
40.00 548.00 FED Withholdng 85.88
40.00 548.00 * FED SS/Dis ER 65.20
* FED MedicareER 15.25
Deductions -
Hours Amoults Add to Gross 14 After-Tax 1.75
44 Before-Tax 41.40
50 Before-Tax 0.66
69 Before-Tax 2.37
12 Before-Tax 127.57
ADP Enterprise HR screen print as of: 06/05/2019 04:18 PM