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Maricopa County Human Resources Memo To Fran McCarroll, Clerk of the Board From: 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 I Year) Duplicate Warrant Thank you. 0? 1 LC :C W,d Z I &II SIN Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or D 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. James A. Rice III (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 04/03/2019 (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/checKbe issued to him/her in the sum of $ 1139.86 .(3) (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 t day of /4)4-1- 20 9AQ,A1,6102.1011M NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Pubic- State °Minna My commission expires: MARICOPA Commission COUNTY # 554$49 I --q -(91) DO. Expires November 9, 2022 (seal) Warrant/Check Number 22644490 (if known) (6) Original Date of Issue 04/03/2019 (if known) (7) Reason for original issue of Warrant/Check (8): I* Payroll El For Services or Goods furnished LI Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 fk 11-644 Rice III,JamesA Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: NEX Separate Check # 0 5073 -Training Division Period End 03/24/2019 Reprint: N NEX- Non Exempt Page: 707 Adjustment: N Active 03/04/2019 Reg/FT Line: - Rice III,James A - MC1/NEX Paycheck View MCY-Earnings v Taxes Deductions Garnishments Special Accumulators Distributions Name Rice III,JamesA Confirmed Check Checkti Issue Date Earnings Taxes Deductions Net Pay 22644490 04/03/2019 1,554.40 283.81 130.73 1,139.86 Regularand Overtime Earnings Reg Hours Reg Pay OT Hours OT Pay MedicareEE 40.00 777.20 Withholdng 40.00 777.20 SS/Dis ER MedicareER Other Earnings Code Hours Amounts Add to Gross ADP Enterprise HR screen print as of: 04111/2019 04:25 PM