STAMPED & REDACTED SYLVIA SILVA.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: September 15, 2022 ie,’

Re: Replacement of Lost Payroll Warrants Hold Oo} nad fF

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 Zell Bullis at ext. 60409 for any questions. Please
route approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 4 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: Duplicate or LI state-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.
Sylvia Silva (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 08/17/2022 (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

ww é to him/her in the sum of $597.25 (3)
Signed: KOU (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 sworn to before me this _/9 day of Septembor 2022.
Zunes. Ugo

NOTARY PUBLIC
i a am
My commission expires: : THARIGOPA COUNTY
Ble [Qle | Sac Eyres ‘August 18, 2028 (seal)
Warrant/Check Number
(if known) (6) 23155648
Original Date of Issue
(if known) (7) 08/17/2022
Reason for original issue of Warrant/Check (8):
Payroll
[For Services or Goods furnished pak

[Treasurer's refund/payment
Llother: E 09/16/2022

Revised April 2015 he U “i K. al yong

Active

- Silva, Sylvia
MC1 -Maricopa County
2120 - Election Day Services
ELE-Elections

11/08/2016 Temp/PT

Company: MC1 Off Cycle: N
Pay Group: ELE Separate Check # 0
Period End 08/07/2022 Reprint: N

Page: 1926 Adjustment: N
Line: 5

I

( Paycheck View

Name Silva,Sylvia Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23155648 08/17/2022 507.25 507.25
- Regularand Overtime Earnings - Taxes
Reg Hours Reg Pay OT Hours OT Pay
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross,
EBT 1.00 5 0b ¥
EPS 23.75 23.75 Y :
ETO 32.75 458.50 Y

ADP Enterprise HR screen print as of: 09/15/2022 08:37 AM