STAMPED & REDACTED DENISE WEAVER.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

RECEIVED
From: Monica Reyes JUN 9.8 2027
Date: June 27, 2022 MARICOPA COUNTY

CLERK BOARD OF SUPERVISORS

Re: Replacement of Lost Payroll Warrants Youd Delvcd - AE

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: ml 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.
Denise Weaver (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 6/22/2022 (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 g1372.57 (3)

Signed: Node (L Ironer (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 BY® aay of Yunt 20 yy

OTARY LI

A commission expires:

AMY D. LOPER ]
ee bie ne of Arizona
conn deta iii
Expires Decem| =

Warrant/Check Number

Srereinmom ay [06/22/2022

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

C1 For Services or Goods furnished
O Treasurer's refund/payment
O Other:

06/28/2022

Revised April 2015

( Paycheck View

Name Weaver,Denise M Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23140575 06/22/2022 2,212.73 432.53 407.63 1,372.57
- Regular and Overtime Earnings — ~ Taxes
RegHours _ Reg Pay OT Hours OT Pay FED SSDisMLVEE 131.97
FED MedicareEE 30.87
FED Withholdng 220.33
27.75 566.66 * FED SS/Dis ER 131.97
12.25 250.14 * FED MedicareER 30.87
r OtherEarnings r Deductions
Code _ Hours __ Amounts Add to Gross 301 After-Tax 7.87
HOL 8.00 163.36 Y 82 After-Tax 9.74
VAC 32.00 653.44 ¥ 91B After-Tax 0.75
SH1 8.00 4.00 Y 98B After-Tax 0.50
SH2 5.00 3.75 Y 14 After-Tax 4.20

ADP Enterprise HR screen print as of: 06/27/2022 11:09 AM