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Maricopa County Human Resources 71emo Th Fran McCarroll, Clerk of the Board From: Lisa Platek Date: April 22, 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 'rids application is for: U Duplicate or PO Stale.Datod (deflollIons ate on page 2) STATE OF ARIZONA Noio:thrnbers on Ws form tate:pond to naWaeas en tto COUNTY OF,L,IARIC9H' los toxboo almost 06:11 to page 2 of 1106 tam. s.__)460 wtop (1), being first sworn, upon oath deposes and says: Ket,„,..•• • ••,• On or about tisq6'16 (da1eX2) a warrant/check was Issued to the awe named perSon/entity In the amount as stated below. Such warrani/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 correet and the mount shown Is due and owing, and the applicant 'requests that 'a replacement warrantichecitte, 7. riedit6firkgrin the sum of $ LI/4-6,(f5 • .(3) Signed: (4) N)3f Please attach a copy elle warrant/check -if available and/or any other Vence that a warranOheck was originally issued. ANTHONY S TELo Notary pm.Striti 01Atizona MARIMAC UNTY -4,044ithedisloaXxpireo January 2g020 - Reason for original Issue ofWarrant/theck (0): -)Payroll - El For Services or Goods furnished 0 Treasurer's refund/payment 0 Other: -grasesalviaets' MS. t1.631 kit :VA " • Marcotte,Jason William - MC1/NEX Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Marcotte,Jason William Confirmed Check Check Issue Date Earnings Taxes Deductions Net Pay 22571963 06/13/2018 81.37 -525.00 443.63 r Regular and Overtime Earnings r Taxes Reg Hours Reg Pa OT Hours OT Pa FED' SSDisMLvEE 32.55 FED MedicareEE 7.61 FED Withholdng 22.31 FED SS/Dis ER 32.55 FED MedicareER 761 - Other Earnings Deductions Code Hours Amounts Add to Gross 73 Before-Tax -525.00 ADP Enterprise HR screen print as of: 04/01/2019 03:48 PM