STAMPED & REDACTED MELISSA DEMING.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: July 19, 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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: ivi 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.

Liisi pica ia Ce (1), being first sworn, upon oath deposes and says:
jam aimant

On or about Bol ez. (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 $ Logs: 7 (3)

Signed: PPE hie ol a (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 f ¢ day of wr uly 20 PA

Tn [Megat

NOTARY PUBLIC

My commission expires:
~~

(seal)
Warrant/Check Number “ ate .
apes (6) A bl Uo Yor
Original Date of Issue /) [Le |
(if- known) (7)
Reason for original issue of Warrant/Check (8):
PN Payroll
O For Services or Goods furnished
1 Treasurer's refund/payment . 07/20 A 2022

O Other:

Revised April 2015 At ACL tat) ya

( Paycheck View

Name Deming,Melissa N Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay |
23143427 07/06/2022 2,371.20 378.51 370.71 1,621.98 |
- Regular and Overtime Earnings ~~ Taxes - — ~ '
Reg Hours RegPay  OTHours OT Pay on FED SSDisMLVEE 143.29
FED MedicareEE 33.51
41.00 4215.24 FED Withholdng 147.15
34.00 1007.76 | * FED SS/Dis ER 143.29
| = * FED MedicareER 33.51
- OtherEarnings ; Deductions
Code _ Hours Amounts Add to Gross 301 After-Tax 7.87
VAC 5.00 148.20 Y 81 After-Tax 7.45
98B After-Tax 0.50
14 After-Tax 4.51
44 Before-Tax 69.48

ADP Enterprise HR screen print as of: 07/18/2022 02:38 PM