STAMPED & REDACTED JERRY WRIGHT JR..PDF

Stale Dated Warrant Duplicate Warrant

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Daniel Villalba
Date: September 12, 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 Daniel. at ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

Thank you. RECEIVED
SEP 1.2 2022

MARICOPA SOUNTY
CLERK BOARD OF SUPERVISORS {\ "

Replacement Lost Warrant Form 4 02/25/2015
ae

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: Duplicate or OO 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.

Jerry Lynn Wright Jr. (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 98/31/2022 (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

warrant/check be issued to him/her in the sum of $997.37 (3)
Signed: On. Zz 2 (4)
CG a

Note. Piéase attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

iin vi wi) a me this &** day of Sgalembey 20.22.
MV Vit

NOTARY PUBLIC ELWABETH S VALENZUELA
My commission expires: ASORMISSION @ 57200
Oc { vhey 24, 043 NOSES soon (seal)
ly _
Warrant/Check Number oe
(if known) (6) 23189322
| Original Date-of Issue-——
(if known) (7) 08/31/22
Reason for original issue of Warrant/Check (8):
Payroll
1 For Services or Goods furnished
O Treasurer's refund/payment
= 09/12/2022

O Other:

Revised April 2015 <f U q ne cla jag

( Paycheck View

Name Wright Jr,Jerry L Confirmed Check

7
|
Check# Issue Date Earnings Taxes Deductions Net Pay
23159322 08/31/2022 793.50 99.56 96.57 597.37
~ Regular and Overtime Earnings
RegHours  RegPay — OTHours OT Pay SSDisMLVEE 49.20
MedicareEE 11.51
30.00 793.50 FED Withholdng 20.00!
* FED SS/Dis ER 49.20
* FED MedicareER 11.51
~ OtherEarnings - > Deductions '
Code _ Hours Amounts Add to Gross; 14 After-Tax 1.11
12 Before-Tax 95.46
* 12 Nontaxable 95.46
* 14 Nontaxable 1.11

ADP Enterprise HR screen print as of: 09/12/2022 12:13 PM