STAMPED & REDACTED TANMAY MUSALE.PDF

Maricopa County
Human Resources

Memo e
a
To: Juanita Garza, Clerk of the Board S

From: Lisa Platek :

Date: July 20, 2022 =

Re: Replacement of Lost Payroll Warrants

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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 Lisa at ext. 63619 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 02/25/2015

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

This application is for: el 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.

Tanmay Musale
Name/Claimant

On or about 97/06/2022 (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.

(1), being first sworn, upon oath deposes and says:

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 41 125.44 18)

Signet: _ nee Pretip Muscle (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 (a day of ‘tly, 2d / x
Qnuiau Gnu abr
NOTARY PUBLIC
Rn, DOMINTGUE STIVER BABCOCK
commission expires; ) _ MARICOPA COUNTY
SEPTEMBER 11, 2024 (se he
Warrant/Check Number S
(if known) (6) 4. 3) 43 S00 ; _
Original Date of Issue wo
(if known) (7) t / ( [ a =
Reason for original issue of Warrant/Check (8): 2
& Payroll i)
O For Services or Goods furnished Ps | &

O1 Treasurer's refund/payment i
1 Other: TE 07/21/2022

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notic fue U q K L lal aK

Revised April 2015

( Paycheck View

Name Musale, Tanmay P

Issue Date
07/06/2022

Check#
23143500

Earnings
1,220.00

Confirmed Check

Taxes Deductions

94.59

Net Pay
4,125.41

- Regular and Overtime Earnings
Reg Hours Reg Pay OT Hours

OT Pay

40.00.
40.00

610.00
610.00

Taxes
FED Withholdng

AZ Withholdng

E OtherEamings

Code Hours Amounts

Add to Gross

- Deductions

ADP Enterprise HR screen print as of: 07/20/2022 11:35 AM

#32 SrnartCompliance’ Updated 02/10/2022

HOME — PROCESSES

Management & Reversals _

Look up the details of a single payment or range of payments by using the form below.
NOTE: The maximum check range is limited to 50 checks per request.

CHECK SEARCH DIRECT DEPOSIT SEARCH

BRANCHCOMPANYCODE = ‘CHECK NUMBER | 23143500 |

{J Range of Check Numbers

(Fy Range of Dates
~ STATUS: ALL ©

# 23143500

Musale Tanmay P
Stopped/Void as of 07/20/2022

$125.41 issued on 07/06/2022