STAMPED & REDACTED-ANTHONY ZARATE.PDF

Maricopa County
Human Resources

VMemo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: March 5, 2025

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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant Duplicate Warrant

Thank you.
McsO

Replacement Lost Warrant Form | 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: mM Duplicate or CX 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.
Ah ony e crete (1), being first sworn, upon oath deposes and says:

Name/Claimant
On or about % ly A p CA (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 i in the sum of § sa v) “4if G05 3)

Signed: Roky Jew et = ee (@)

Note. Please sttoch 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 Marcin 2025.

NOTARY PUBLI! ;

Watany Public - Arizona
Maricopa County *

M Commleaton # 672813
y commission expires: My Commission Expires Auguat 14, 2028

Ag Vy 267 : teary

Warrant/Check Number : ;
(if known) (6) S30 7330

Original Date of Issue ANAalac
(If known) (7)

Reason for original issue of Warrant/Check (8):
LY Payroll / 3/6/25

O] For Services or Goods furnished
O Treasurer's refund/payment
O Other:

Revised April 2015 ARS. 11-632 & 11-644

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 8500
Anthony Zarate

24 (602) 5063519

(Current

4,905.91

2.86 4,378.53

(YTO

1,905.91

2,86) 1,378.53

Dates

Description Description

Admin Leave With 02/10/2025 - 02/16/2025 2 45.94 2 45,94} JOASDI 41847 118.17
Regular Pay 02/03/2025 - 02/16/2025 380 1,837.60 80 1,837.60] [Medicare 27.64 27.64
Shift Differential Thi02/03/2025 - 02/16/2025 8.5 6.37 8.5 6.37| [Federal Withholding 122.59 122.59)
Shift Differential Tw02/10/2025 - 02/16/2025 32 16.00 32 16.00] {State Tax - AZ 25.12 25.12
Eamings 4,905.91 1,905.91] | Employee Taxes 293.52 293.52

(Description Amount YTO} [Description Amount YTD)
IDB - ASRS 231.00 231.00] |ASRS LTD 2.86 2.86
Pre Tax Deductions 231,00 231,00] | Post Tax Deductions 2.86 2.86

Description Amount YTD] [Description Amount YTO!
ASRS LTD 2.86 2,86} JOASDI - Taxable Wages 1,905.91 1,905.94
(DB - ASRS 231,00 231,00; |Medicare - Taxable Wages 1,905.91 1,905.91

Federal Withholding - Taxable Wages. 1,674.91 1,674.91
Employer Paid Benefits 233.86 233.86] {State Tax Taxable Wages - AZ 1,674.91 1,874.94

Marital Status

Single or Married filing

Description
separately Floating Personal Day
lAlowances, ie) 1.50%] Sick - County
Additional Withholding 0 0} [Vacation - County

3.18
4.65

Bank

Account Name Account Number

USD Amount

Amount

‘Check)

1,378.53 USD.