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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: April 26, 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 Monica at x 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant (Over 1 Year) Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. Gregory W. Thompson (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 04/17/2019 (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 $ 1,164.68 .(3) S ig (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 2(-0 day of A-F1/4i 20 tq ?Alt),..1,0*(AWILAN/ JL NOTARY PUBLIC EILEEN WILLIAM&PREAS My commission expires: Notary MARICOPA PublIc.StateefArtzona COUNTY Expires Commission November # 554949 9. 2022 (seal) Warrant/Check Number 22646871 (if known) (6) Original Date of Issue 04/17/2019 APR _2 9 2019 (if known) (7) Reason for original issue of Warrant/Check (8): • Payrol l I For Services or Goods furnished El Treasurer's refund/payment ▪ Other: Revised April 2015 A.R.S. 11-632 & 11-644 Thompson,Gregory Company: MC1 Off Cycle: N MC1 - Maricopa County Pay Group: NEX Separate Check # 0 5073- Training Division Period End 04/07/2019 Reprint: N NEX-Non Exempt Page . 710 Adjustment: N Active 02/04/2019 Reg/FT Line: 7 - Thom pson,Gregory W - MC1/NEX r Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Thompson,Gregory W Confirmed Check Check4 Issue Date Earnings Taxes Deductions Net Pay 22646871 04/17/2019 1,782.40 220.68 397.04 1,164.68 - Regular and Overtime Earnings — Reg Hours Reg Pay OT Hours FED SSDisMLvEE 98.931 FED MedicareEE 23.14, 40.00 891.20 FED Withholdng 61.13 40.00 891.20 FED SS/Dis ER 98.93 FED MedicareER 23.14 Amounts Add to Gross' 14 After-Tax 2.85 43P Before-Tax 159.55 50 Before-Tax 1.95 61 Before-Tax 25.22 12 Before-Tax 207.47 ADP Enterprise HR screen print as of: 04/26/2019 10:12 AM