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Maricopa County Human Resources Memo Fran McCarroll, Clerk of the Board Froraim Monica Reyes Date: April 12, 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) ( Duplicate Warrant Thank you. LC :C V4c1 Z I 88v 610Z •-I l• f 1 Appiication for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: El 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. 01611(1 Cers) OUrnli:JA Eb 1 C (1), being first sworn, upon oath deposes and says: vilf7''trie77777t. 1 ()L1 1 V CI On or about ) L3.1 I (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 $ 0 9 (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. ubscri ed and sworn to before me this li-rkt day of 4\jeg11-- 20 VA . matgan Wa M commission expires: Nam Public MiticuPaCountY' AilicAla *Conn. Expires 01-0451) Warrant/Check Number (if known) (6) Lo4 4 51 Original Date of Issue 0L--1 03 I ezo (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll 111 For Services or Goods furnished 0 Treasurer's refund/payment 'IQ other: n_e r fe c-e wed pctch-e_c. actci ye _cs u3CIf,' uor0 tP\O - Revised April 2015 ARS. 11-632 & 11-644 Contreras Castaneda,Maria D Company: MC1 Off Cycle: N MC1 - Maricopa County Pay Group: NEX Separate Check # 0 5123- Durango Jail Period End 03/24/2019 Reprint: N NEX -Non Exempt Page 859 Adjustment: N Active 03/11/2019 Reg/FT Line: - Contreras Castaneda,Maria D - MCVNEX r Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Contreras Castaneda,Maria D Confirmed Check Check # Issue Date Earnings Taxes Deductions Net Pay 22644512 04/03/2019 1,802.14 187.49 151.56 1,463.09 Regular and Overtime Earnings - Taxes --- Reg Hours Reg Pay OT Hours FED SSDisMLvEE 111.73: FED MedicareEE 26.131 FED Withholdng 5.06 * FED SS/Dis ER 111.73: * FED Medicare ER 26.131 OtherEarnings - - Deductions Code Hours Amounts Add to Gross 18 Before-Tax VAC 0.25 5.55 Y 18 Nontaxable AWP 1.25 27.73 ADP Enterprise HR screen print as of: 04/12/2019 11:53 AM