STAMPED & REDACTED LAURA MARTINEZ.PDF

Maricopa County

Human Resources

VMiemo

To: Cindy Goelz, Clerk of the Board

RECEIVED

AUG 2% 2622
From: Zell Bullis CLERK BOARD OF SUPERVISORS
Date: August 2, 2022 HorD Dewed -AP

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, Suite 400.

Stale Dated Warrant [Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 04/08/2021

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: (zl Duplicate or CO 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.

Laura Martinez (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 5/11/2022 (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 g41 2.35 (3)

Signed: _ Soe é Wie be (4)

te. Please attach Scopyof 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 ' \n day of i A IM 20 2a
Anata lay

NOTARY PUBLIC
Commission #622445

My commission ires:
rw wees ~ OUD My Comm. Expires Feb. 8, 2026
Werawnecnombe 19993131483.

(if known) (6)

Original Date of Issue
(if. known) (7) 5/1 4 /2022

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

Cl For Services or Goods furnished

SHALLA COLE
Notary Public - Arizona
Pinal County

Cl) Treasurer’s refund/payment = 08/02/2022

C1 Other: Aucncti aye

Revised April 2015

811140294 - Martinez,LauraM Company: MC1
MC1 - Maricopa County

Pay Group: NEX
6522 - Queen Creek Branch | Period End 05/01/2022
NEX-NonExempt

Page: 1060
Terminated 07/24/2022 Reg/PT

| Line: 5

Off Cycle: N
Separate Check # O
Reprint: N
Adjustment: N

Paycheck View

Name Martinez,Laura M Confirmed f Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23131483 05/11/2022 464.63 52.28 412.35
- Regularand Overtime Earnings : TEE ~ Taxes
Reg Hours Reg Pay - OT Hours OT Pay FED _SSDIsMLVEE 28.61
; FED MedicareEE 6.74
43.00 191.75 : : * FED SS/Dis ER 28.81
18.50 __ 272.88 2 re MedicareER 6.74
: AZ es Withholdng 16.73)
> Other Earnings 7 Deductions
Code _ Hours © Amounts. Add to Gross

ADP Enterprise HR screen print as of: 07/29/2022 07:53 AM