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Maricopa County Human Resources 2019 APR 18 PH 3:06 00, 0,6\9A Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: April 17 , 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 10002102110ELEC10000 P21002 Dept: 2110— Elections Operations tale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 02125/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: El Duplicate or I 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. Suaava, Savannah Malia (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 is7torreq l and the amount shown is due and owing, and the applicant requests that:_,a4eplae9meill 0 warrant/check be issued to him/her in the sum of $ 1,351.29 3) m 1 -1 Signed: m Note: Please attach a copy of the warrant/check if available and/or:a%other evidence that a warrant/check was originally issued. (5) Subscr . adAP : orn to before me this //41L' day of 20 . rispAa.,/ fe RY P commi ionexpires: HOPE M. OLGUIN NotaryPubllo- MAR ICOPA State COUNTY of A rtz04711 (seal) My Commission Expires Aprti 4,2022 Warrant/Check Number (if known) (6) 22603463 Original Date of Issue (if known) (7) 09/19/2018 Reason for original issue of Warrant/Check (8): Payroll CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY O For Services or Goods furnished ElTreasurer's refund/payment O Other: Revised April 2015 A. R.S. 11-632 & 11-644 -Suaava,Savannah M Company MC1 Off Cycle: N MCI- Maricopa County Pay Group: ELE • Separate Check # 0 2110- Operations Period End 09/09/2018 Reprint: N NEX -Non Exempt Page 2808 Adjustment: N Active 10/10/2018 Temp/PT Line: 6 - Suaava,Savannah M - MC1/NEX Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Suaava,Savannah Malia Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 22603463 09/19/2018 1,351.29 1,351.29 1 Regular a nd Overtime Earnings Taxes Reg Hours Reg Pay OT Hours Other Earnings Deductions Code Hours EER 10.00 Y EMR 562.00 306.29 ECC 69.00 1035.00 ADP Enterprise HR screen print as of: 04/16/2019 10:07 AM