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flLLV VI' 411aricopa County Human Resources 2019 MAY -6 An 2:22 Fran McCarroll, Clerk of the Board Zellnor Bullis May 3, 2019 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 10002102120ELEC10000 P21047 Dept: 2120— Elections Stale Date( 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: 0 Duplicate or g 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. Barbara A Bartlett (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 09/19/2018 (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 tsum of $ 115.50 .(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 20 19 . atitAiL-#(..1) NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Pubic. State of Arizona My commission expires: M.ARICOPA COUNTY -4 -- 2t02-2-- Expires Commission November #554349 9, 2022 (seal) Warrant/Check Number 22603731 (if known) (6) Original Date of Issue 09/19/2018 (if known l (7) Reason for original issue of Warrant/Check (8): El Payroll El For Services or Goods furnished El Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Bartlett, Barbara Ann Company: MC1 Off Cycle: N MC1 - Maricopa County Pay Group: ELE Separate Check # 0 2120- Election Cycle Period End 09/09/2018 Reprint N ELE- Elections Page. 158 Adjustment: N Active 11/04/2008 Temp/PT Line: 5 - Bartlett,Barbara Ann - MCl/ELE CY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Bartlett, Barbara Ann Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 22603731 09/19/2018 115.50 115 50 r Regular and Overtime Earnings Reg Hours Reg Pay OT Hours OT Pa — Other Earnings Code Hours EPW 10.50 115.50 ADP Enterprise HR screen print as of: 05/03/2019 10:28 AM