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BOARD VIARICOP'A OF SUeE7:::1.-L, Maricopa County Human Resources 21J1 MAY 31 PM 2: ! 'D2-\ Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton 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 Debbie U. at ext. 66329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated 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: t 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. (1), being first sworn, upon oath deposes and says: ame anent On or about e2s"--/&/e-i/' (date)(2) a warrant/check was issued to the above named persein/errtity 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 $ .(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 ) Sub /bed and -w--01-110 before me this '3 1 3t day of 20 .ii_ X .71 A I I A yl NOTARY PUBLI PATRICIA QUEVEDO My commission epires; 110024iRtYY PPIEL -424412111112 --11AARRI12(11oI 22112 Ma2 Ai 2222 (seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Reagn for original issue of Warrant/Check (8): Payroll 111 For Services or Goods furnished -w- L1 Treasurer's refund/payment II] Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Valencia,Judith L Company. MC1 Off Cycle: N MC1-MaricopaCounty Pay Group: NEX Separate Check #: 0 5111 -Central Intake Period End 04/21/2019 Reprint: N NEX-Non Exempt Page: 747 Adjustment: N Active 04/01/2019 Reg/FT Line: Valencia,Judith L - MC1/NEX , .., Paycheck View MCY - Earnings Taxes Deductions Garnishments Special Accumulators i Distributions Name Valencia,Judith L Confirmed Check Check il Issue Date Earnings Taxes Deductions Net Pay 22649289 05/01/2019 1,733.48 246.94 133.47 1,353.07 Regular and Overtime Earnings A Taxes' Reg Hours Reg Pay OT Hours OT Pa, FED SSDisMLvEE 107.48 I FED MedicareEE 25.14 40.00 837.20 FED Withholdng 85.30 39.50 826.74 FED SS/Dis ER 107.48 * FED MedicareER 25.14 i OtherEamings -- A -- Deductions Code Hours Amounts Add to Gross 375 After-Tax 12.13 SH2 38,75 29.06 Y 373 Before-Tax 121.34 SH1 1.00 0.50 373 - Nontaxable 86.67 SH2 38.50 28.88 38 Nontaxable 324.33 VAC 0.50 10.47 * 375 Nontaxable 12.13 ADP Enterprise HR screen print as of: 0513112019 02:37 PM