STAMPED & REDACTED MARGUARITA HERNANDEZ.PDF

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.

~ Stale Dated Warrant ~————~SsS*éS a licate@ Warrant

Thank you.

Replacement Lost Warrant Form

. 02/25/2015
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Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form

This application is for: Duplicate or C1] 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.
Marguarita Hernandez (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 $1275.43 (3)

Signed: Waputte Yom (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) ne sworn to before me this _ | y** day of Depke miaod 202.7.

a.
NOTARY PUBLIC Se

My commission expires:
QAI Ts

MIRE HERMEZ
Notary Public - Arizona
Maricapa County
Commission # 600908
My Comm. Expires Apr 11, 2025

(seal)

Warrant/Check Number
___(ifknown) (6) 23158982 _ |
Original Date of Issue
(if known) (7) 1;275.43

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

O For Services or Goods furnished

C] Treasurer's refund/payment
C1 Other: = 09/12/2022

Revised April 2015 <f UGK cla jag

Name Hernandez,Marguarita J Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23158982 08/31/2022 1,604.80 134.06 195.31 1,275.43
7 Regularand Overtime Eamings “rr eS 7 Taxes
Reg Hours RegPay  OTHours OT Pay 7 FED SSDisMLVEE 99.50
FED MedicareEE 23.27
40.00 802.40 _* FED SS/Dis ER 99.50)
40.00 802.40 * FED MedicareER 23.27
AZ Withholdng 11.29)
- OtherEarnings - Deductions ~ ns
Code Hours Amounts Add to Gross 14 After-Tax 2.25
12 Before-Tax 193.06
12 Nontaxable 193.06
14 Nontaxable 2.25

ADP Enterprise HR screen print as of: 09/12/2022 12:14 PM