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Maricopa County Human Resources iOt Fran McCarroll, Clerk of the Board From: Debbie U. Date: March 14, 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 Debbie U. at ext. 66329 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 L Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. Geneva L Vinciguerra (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 3/6/2019 (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 $ 1041.50 .(3) Signed: d (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. sworn to before me this IV-FA \ day of #14 gieStalta OFFICIAL SEAL e9j1 d. AUDRA EVANS My commission expires: NOTARY MARICOPA PUBLIC COUNTY - ARIZONA COMM. # 548928 My Comm. Expires June 13,2022 (seal) • " Warrant/Check Number 0022639587 (if known) (6) Original Date of Issue 3/6/2019 :13 •••I•I• (if known) (7) cD Reason for original issue of Warrant/Check (8): ‘.9 Payroll El For Services or Goods furnished II] Treasurer's refund/payment LI Other: Revised April 2015 A.R.S. 11-632 & 11-644 - Vinciguerra,Geneva Company: MC1 Off Cycle: N . . A ar i copa coplti n ri._.Pay 1 Group: NEX Separate Check #: 0 I A. 4u2 - Encanto J U 5- W (2- e - L: 0 a Period End 02/24/2019 Reprint: N NEX - Non Exempt Page: 315 Adjustment: N V Active 08/04/1997 Reg/FT Line: 1 811046992 - Vinciguerra,Geneva - IVIC1/NEX Paycheck View j MCY-Eamings 1 Taxes j Deductions Garnishments ' Special Accumulators Distributions Name, Vinciguerra,Geneva Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 22639587 03/06/2019 1,987.57 353.66 592.41 1,041.50 i , - Regular and Overtime Earnings — - Taxes Reg Hours Reg Pay OT Hours OT Pay _ FED SSDisMLvEE 109.63, ... FED MedicareEE 25.64. • 0.75 18.38 FED Withholdng 140.02: . ,. .,.. 29.50 722.75 FED SS/Dis ER 109.63! I 18.50 453.25 , * FED MedicareER 25 ' 64 1 1 __ F 1 Other Earnings - - - — - Deductions , Code Hours Amounts Add to Gross 104 After-Tax 100.00 i I 1 OTP 2.25 82.69 Y 81 After-Tax 7.01 VAC 11.50 281.75 Y 91A After-Tax 1.53 HOL 8.00 196.00 Y 92 After-Tax 28.97 VAC 9.50 232.75 Y 98A After-Tax 0.84 -7.- ADP Enterprise HR screen print as of: 03/14/2019 09:11 AM