STAMPED & REDACTED TANIA DIAZ FERNANDEZ.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: September 8, 2022

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

Stale Dated Warrant Duplicate Warrant
ECEIVED

Thank you. “EIVED
SEP ~ 8 2072

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

Replacement Lost Warrant Form 1 08/02/2022

Yen

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

This application is for: “i Duplicate or C] 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.

a 4 +
bya Diae Ferman dee (1), being first sworn, upon cath deposes and says:
am alman'

. ‘
On or about _. 8 lA 31/2029 . (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
ho 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 tb him/her in the sum of ¢ 5 6.00 (3)
Signed: a (4)

FS

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_ 7th day of Septeber 208A,

Bet, AM lbarby As
NOTARY PUBLIC

SCOTT MULLENBAGH

My commission expires: vit ay
R-3- 2026 Hy on 88 (seal)
Warrant/Check Number
check Nu 0023/5271)

Original Date of Issue

5 (Fknown) (7) B/31/ BAR
Reason for original Issue of Warrant/Check (8):

44 Payroll

C For Services or Goods furnished

O Treasurer's refund/payment 09/09/2022

OD Other: ; :

Revised April 2015

-Femandez, Tania D ‘Company: MC1 Off. Cycle: N
MC1 -Maricopa County _. Pay Group: EXM Separate Check #0
2220 - Early Education | Period End 08/21/2022 Reprint: N
i EXM-ExemptEEs H Page. 853 Adjustment: N
le _|, Active 08/15/2022 Reg/FT Line; 5, ;

(1 Paychack View rar

Rainings | Taxes [De
Name. Fernandez, Tania D Confirmed Check
Check# Issue Date Earnings : Taxes Deductions‘. ~ Net Pay.
23158914 08/31/2022 720,00 63.31 87.63 569.06 |
~Regularand Overlime Earnings -- - =I FAXeS mein ao - es
RegHours Reg Pay... OT Hours OT Pay FED SSDisMLVEE A464
: FED MedicareEE. 10.44
40,00 720:00 : +" FED $$/Dis ER si 4464
* FED: MedicareER 10.44
ace Withholdng 8.23
» OtherEamings ==> es sj Deductions oes rar
Code ~ Hours Amounts. Add to Gross ics After-Tax eo
a ae ay med : ue Before-Tax OS i BOO2
2 Nontaxable : 86.62
*44 Nontaxable we 4.01

ADP Enterprise HR screen print as of: 09/08/2022 01:17 PM