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Maricopa County js Human Resources Vemo To: Fran McCarroll, Clerk of the Board e ms From: Wanda Childers o a Date: December 23, 2015 Qe Re: © Replacement of Lost Payroll Warrants oz = 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 Wanda at ext. 60409 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 Affidavit/ Claim Form Er Stale erie SOLL/RECORDS This application is for: LC] Duplicate or bane (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. Psa tu 0; hice RAZO (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 5 9071S — (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 $ /| Ca,Y) (3) ite Note, Please attach a copy warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this __["ék day of _ écernloe 20_is ‘nuehibli) ber eli? NOTARY PUBLIC MICHELLE D. GONZALES My commission expires: NOTARY PUBLIC - ARIZONA MARICOPA COUNTY alialia My Comm. Exp.: July 19, 2019 (seal) Warrant/Check Number ardAme: _ aed [101% (if known) (6) Original Date of Issue Pee ae 29 l5 (if known) (7) Reason for original issue of Warrant/Check (8): . [1 Payroll = Was unaware Check had been issued Qna inaducrten(y (ast 1 For Services or Goods furnished C11 Treasurer's refund/payment (11 Other: | APPROVED | Revised April 2015 | A.R.S. 11-632 & 11-644 [MI - Cabrera-Razo,Rosalie M-MCA1/NEX Taxes | Deductions [ Garnishments — Sn Distributions Paycheck View | Earnings - ot S : MCY-Earnings : . Name Cabrera-Razo,Rosalie M Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay . ADP Enterprise HR screen print as of: 12/23/2015 12:10 PM .Wanda Childers - HRX From: Renee Hernandez - HRX Sent: Friday, December 18, 2015 12:07 PM To: Wanda Childers - HRX . Subject: FW: Staledated Check Attachments: aff_lost_wage.pdf Here is the email. Renee Hernandez Payroll Accountant Maricopa County Human Resources — “Your Partner for Success” hernandezr033@mail.maricopa.gov Tel: 602.506.7094 Fax: 602.372.0277 http://www.maricopa.gov/human_resources/ 301 W Jefferson, Phoenix, AZ 85003 From: Renee Hernandez - HRX : Tanee orris - HRX; Troy Marshall - HRX Subject: Staledated Check Ms. Cabrera-Razo, We received notification from ADP that a payroll check that was issued to you on 05/20/2015 in the amount of $1152.47 on Check # 22279078 was never negotiated. The check is no longer negotiable and would need to be re- issued. Please complete the attached Affidavit with Notary signature and provide the original copy to the Payroll . Department for re-issuance of your check. You can contact the front desk at 602-506-3519 for further assistance on how to submit the Affidavit . Thank you, Renee Hernandez Payroll Accountant Maricopa County Human Resources — “Your Partner for Success ” hernandezr033@mail.maricopa.gov Tel: 602.506.7094 Fax: 602.372.0277 http://www.maricopa.gov/human_resources/ nt