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Maricopa County Human Resources Memo 11=2 5- Xf.• To: Fran McCarroll, Clerk of the Board From Zellnor Bullis Date: March 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 Zellnor B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ACCT/FUND: 100D2102120ELEC10000 P21047 Dept: 2120— Elections Stale Dated Warrant Thank you. Replacement Lost Warrant Form 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or 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. Jerry Allen Broadbent (1), being first sworn, upon oath deposes and says: Name/Claimant On or about November 28, 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 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 $ 211.75 .(3) 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 day of L.A.A 2 0 \ 9 . 1-k COLLEEN M. REDMOND Notary Public - State of Arizona My Commission MARICOPA Expires COUNTY May 9, 2022 (seal) Warrant/Check Number (if known) (6) 22620222 Original Date of Issue (if known) (7) 11/28/2018 Reason for original issue of Warrant/Check (8): )V Payroll R 1 8 2019 El For Services or Goods furnished ElTreasurer's refund/payment Other: Revised April 2015 A.R.S. 11-632 & 11-644 11111.1111- Broadbent,Jer Allen Company: MC1 Off Cycle: N MCI - Maricopa County Pay Group: ELE Separate Check # 0 2120- Election Cycle Period End 11/18/2018 Reprint: N ELE- Elections Page 305 Adjustment: N Active 11/06/2007 Temp/PT Line: 5 - Broadbent,Jer Allen - MC1/ELE r Paycheck View MCY-Earnings rTaxes Deductions Garnishments Special Accumulators Distributions Name Broadbent,Jerry Allen Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 22620222 11/28/2018 211.75 211.75 Reg ular and Overtime Earnings - --- - Taxes Reg Hours Reg Pay OT Hours OT Pay Deductions EPW ADP Enterprise HR screen print as of: 03/12/2019 03:45 PM