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Maricopa County Human Resources Fran McCarroll, Clerk of the Board rim:am Linda Greinke !late: February 28, 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 Linda. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form mv.25E0'1P,"°' 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. Daren K Frank (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 02/12/2019 (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/check be issued to him/her in the sum of $ 16,127.44 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. (5) Subscribed and sworn to before me this a day of F'-e-6 20 . NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Pubic- State of Arizona My commission expires: MARICOPAcouNTY Commission #654349 t -q - Expires November 9, 2022 (seal) Warrant/Check Number 2300632 (if known) (6) Original Date of Issue 02/12/2019 (if known} (7) D Reason for original issue of Warrant/Check (8): Payroll 0 For Services or Goods furnished 0 Treasurer's refund/payment III Other: Revised April 2015 A.R.S. 11-632 & 11-644 811052859- Frank,Daren K - MC1/EXM Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions _ Name Frank,Daren K Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 2300632 02/12/2019 25,224.32 8,019.14 1,077.74 16,127.44 - Regular and Overtime Earnings Taxes Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLNEE 1,551.68 40.00 2652.40 FED MedicareEE 362.89 1 FED Withholdng 5,080.52 * FED SS/Dis ER 1,551.68 * FED MedicareER 362.89 Other Earnings Deductions Code Hours Amounts Add to Gross! 143 After-Tax LVN 340.40 22571.92 Y 186 After-Tax 91A After-Tax 92 After-Tax 98B After-Tax ADP Enterprise HR screen print as of: 02/28/2019 09:58 AM