STAMPED & REDACTED MAYA CRUZ.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: May 25, 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

pur

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

This application is for: THouptcate or CJ Stale-Dated (definitions are on page 2)

7

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

On or about (4) l] | LA (date)(2) a warrant/check was issued to the
above named person/éntity 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 nar; mo a replacement

my d Ve to him/her in the sum of $ lA. 4 = .(3)

(4)

Not ATA “Sach @ copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

Signed:

(5) Subscribed and alec me this | day of Mou 20,
“Paclos ' —_
Ny

NOTARY PUBLIC BELEN CASTILLO
Pubic - Stata of Arizona
My commission expires: Conninckn # baits
( OS : 2 Se ee ate
Warrant/Check Number Be
(if known) (6) 23131425 5
Original Date of Issue
(if known) (7) 5/11/2022 =
Reasan for original issue of Warrant/Check (8):
Payroll
0 For Services or Goods furnished
OD Treasurer's refund/payment
0 Other: 05/26/2022
Revised April 2015

( Paycheck View

Name Cruz,Maya K Confirmed

Check
Checkd Issue Date Earnings Taxes Deductions Net Pay |
23131425 05/11/2022 1,740.00 278.11 268.97 1,192.92
~Regularand Overtime Earnings r Taxes : :
RegHours  RegPay _ OTHours _ OT Pay di a, shag
FED MedicareEE 24.46
40.00 870.00 FED Withholdng 409.25
40.00 870.00 | * FED SS/Dis ER 104.59
| * FED MedicareER 24.46
r OtherEarnings — - ae - Deductions - :
Code _ Hours Amounts _ Add to Gross | 14 After-Tax 3.34
| 44 Before-Tax 43.40
| 50 Before-Tax 0.66
' 64 Before-Tax 8.97
| 12 Before-Tax 212.63

ADP Enterprise HR screen print as of: 05/25/2022 11:54 AM