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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: March 21, 2019 Re: Replacement of Lost Payroll Warrants Please find attached 'I 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: 100D2102120ELEC1000 P21047 Dept: 2120— Elections Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 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. E. 1- L V] (/ ‘ (1), being first sworn, upon oath deposes and says: ame/Claiman 0 On or about t a.AZ—‘ 2-0 I r (date)(2) a warrant/check was issued to the above named person/enti 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 $ 2-14- • 0 0 .0) Signed: •A e— )'O (4) Note: Please attack el 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- 1 day of Marc-111 20 FLUA1L-1.0 ACAANO-RibW NOTARY PUBLIC EILEEN WILLIAMS-PREAS My commission expires: Notary MARICOPA Public - State COUNTY olArizona I I—cr. 2Dila Expires Commission November #554349 9, 2022 (seal) Warrant/Check Number - (if known) (6) Original Date of Issue APPRO (if known) (7) DATO 0 2019 Reason for original issue of Warrant/Check (8): LI Payroll OAAD OF SJPERVISOHS MARICOPA COUNTY For Services or Goods furnished 111 Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644 Wong,Helen Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: ELE Separate Check # 0 2120- Election Cycle Period End 12/02/2018 Reprint: N ELE - Elections Page: 2886 Adjustment: N Active Line: 6 811104654 -Wong,Helen MC1/ELE ( Paycheck View CY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name VVong,Helen Confirmed Check Checki4 Issue Date Earnings Taxes Deductions Net Pay 22624193 12/12/2018 294.00 294.00 Regular and Overtime Earnings • r Taxes Reg Hours Reg Pay OT Hours Other Earnings Deductions Code Hours ECB 28.00 ADP Enterprise HR screen print as of: 03/21/2019 01:25 PM