STAMPED & REDACTED - WILLIAM MORTENSEN.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: November 17, 2022

Re: Replacement of Lost Payroll Warrants

6 HV 81 AON 2202

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.

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form Count
This application is for: i Duplicate or oO Stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
OUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

l Je, Laan MorreXoe0 (1), being first sworn, upon oath deposes and says:
On or about _22-Sepr- O27 _ (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

en TS the sum of $223.90 3)
Signed: iD = (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 iL we me this__/¢- day of Abu 2022.
. fs re fi

NOTARY PUBLIC * /

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My commission expires: pai even Coury
My, G+ FeeDG ee My Conte oe Nag ot 5 (seal)
—_— a ——
| Warrant/Check Number | “7 ieoegi €
een a 3 \e53Ss3 .

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Original Date of Issue
i (if known) (7) M\ \asynr-

Reason for original issue of Warrant/Check (8):
® Payroll

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

11/18/2022

Revised April 2015

( Paycheck View

Name Mortensen, William R Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23165353 09/28/2022 242.64 8.74 233.90
~ Regularand Overtime Earnings ‘ona r Taxes a -
RegHours _Reg Pay OT Hours. OT Pay _ AZ Withholdng 8.74
r OtherEarnings : Deductions
Code Hours Amounts Add to Gross
HPR 242.64 Y

ADP Enterprise HR screen print as of: 11/17/2022 06:00 PM