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Maricopa County Human Resources Memo c. -74 s=I To Fran McCarroll, Clerk of the Board From: Zellnor Bullis •1:0 .L"'• Date: March 21, 2019 cJ C) 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: 100D2102120ELEC1000 P21047 Dept: 212.0 lectiQns ale Dated Warrant Duplicate 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. II1 V.) 0 N (1), being first sworn, upon oath deposes and says: Name /Claimant On or about 7( 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 $ ' 8 .(3) Signed: :1- (4) Note: Please attach a 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 21 day of 01\0arth 20 lq . au, bouLL.07,,v)_.pro,sk7.‘) NOTARY PUBLIC EILEEN WILLIAMS-PREAS My commission expires: Notary Public - State of Arizona MARICOPA COUNTY eal) Commtsebn #554349 Expires Noventet 9,2022 Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): DATE MAR 2 6 2019 El Payroll Eli For Services or Goods furnished LI Treasurer's refund/payment 111 Other: Revised April 2015 A.R.S. 11-632 & 11-644 11111111-Wong,Helen Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: ELE Separate Check # 0 2120- Election Cycle Period End 09/09/2018 Reprint: N ELE -Elections Page, 2649 Adjustment: N Active Line: 6 811104654 -Wong,Helen - MC1/ELE ( Paycheck View CY- Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Wong,Helen Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 22604474 09/19/2018 391.38 391.38 , Regular and Overtime Earnings - Reg Hours Reg Pay OT Hours OT Pay OtherEarnings - • Deductions Code Hours Amounts Add to Gross EPVV 35.58 391.38 ADP Enterprise HR screen print as of: 03/21/2019 01:25 PM