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\ on “al oa ee OES Human Resources oS ULI OCT 13. to PM Frat? 2:12 Vviemo To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: October 13, 2015 Re: Replacement of Stale Dated Warrant 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. Please call Linda G. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. ~ Stale Dated Warrant ™ Duplicate Warrant ) eo 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: L] Duplicate or WX stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY Instruction sheet which is page 2 of this form (ont UST LN ABOUKE = (1), being first sworn, upon oath deposes and says Name/Claimant On or about 2-274 (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 be issued t in the sum of $ Al. 6 (3) warrant/cnecks ee ( tigaxs w2Z. Lo - Signed: LA (4) 3 hi, fhe Note. Please att, a copy of warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this Ke) day of Oct 2015. NOTARY PUBLIC My commission expires: \\- OF -AOIR 7) Warrant/Check Number OO 22 ; [lo7 L7Z (if known) (6) Original Date of Issue 2 _ ZL = } a7 (if known) (7) Ls Reason for original issue of Warrant/Check (8) Payroll [] For Services or Goods furnished Uv C1 Treasurer's refund/payment ie 2 C] Other: Revised April 2015 A.R.S. 11-632 & 11-644 ( Paycheck View |(/MCY#Earnings™ // Taxes” Aen Gabettel Aledetus Ganiatees Check Austin Check# Issue Date Earnings Taxes Deductions Net Pay 22167672 02/26/2014 41.00 41.00 Lei Ee Be eS eee AROS eee a eae tee ES eee athe eames) ee won! Fe REE ES Se SE es Se ee ee fi Regularand Overtime Earnings ~ nn See eae Taxes — FEE SES ELE ee eS | RegHours Reg Pay OT Hours OT Payas Bn _—_ = ac Hiner eamindes ER Deductions Mite see mar ef | “Hours Add to Gross - = Code Amounts ea _ _ DCY 41.00 Vf @ WWERIEY DOCUMENTAUTHENTICY PIC OLOBED AREA USTICHANGESN TONEIGHADUALLYANDIEVENDYIEROMDABKATM OPM OMNGH IER IAIss07 TOM 91-527/1221 Maricopa County W. Jefferson St. ereck Dumber: ; eres 301 Suite 220 Phoenix, Az. 85003 Check Date: 02/26/2014 ISSUED BY ADP PAYROLL SERVICES, INC. GA 2 This amount: to tas oe Austin A Gaboure ASSISTANCE WITH VERIFICATION AVAILABLE AT 877-423-7243 order of, i vy Wells Fargo Bank, N.A. Jc Ucsh. in Arizona >>, AQP AUTHORIZED .SIGNATURE . WOOetsbP?bPaw he cbse Pat 9a53040 78 Sie | Mo PH OHIGINAL DOCUMENT HAS AN AATIFICI Warrerll HON THE SAC. BPO HOLD AT AN ANGLE TO VIEW WHEN CHECKING THE SNDOHSEMENT Reason +o Yeitssve check ‘ /Was out OF Jows) 00 TINE CHECK WAS MalleD 2v7— DE G12 190 EL bec]