STAMPED & REDACTED CATHERINE MICELI.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes CLERK BOA LIPERVISORS

Date: April 18, 2022 HP Beluud AF

Re: Replacement of Lost Payroll Warrants

Please find attached _1 __ Affidavit/Notice of Claim(s) for lost

payroll warran‘> *-~‘ yclusion 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, 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: Duplicate or CO 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.
Catherine Miceli (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about _ 4/13/2022 (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 $ 1,129.21 (3)
Signed: Le Ez 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 i3 day of Op 0 2022...
Glow Wama- Rusas

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
= Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 854349 (seal)
Expires November 9, 2022

My commission expires:

-

Warrant/Check Number
(if known) (6) 23125174

Original Date of Issue 4/13/2022

(if known) (7)

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

0 For Services or Goods furnished 04/21/2022
O Treasurer’s refund/payment .
1 Other:

Revised April 2015 AWK.D. 11-092 O LL-OFt

-Miceli,CatherineF Company: MC1 Off Cycle: N
MC1 - Maricopa County Pay Group: NEX Separate Check # 0
5141 - Custodial Services Period End 04/03/2022 Reprint: N
NEX-NonExempt Page 937 Adjustment: N
Active 01/30/2006 Reg/FT Eines ==
- Miceli,Catherine F - MC1/NEX
{ Paycheck View { MCY-Eamings | Taxes | Deductions [ Garnishments [ Special Accumulators 4 Distributions
Name Miceli,Catherine F Confirmed Check and Advice
Check# Issue Date Earnings Taxes Deductions Net Pay
23125174 04/13/2022 1,899.43 179.50 405.72 1,314.21
Check/Advice# Type Account# Amount laa
3651363 Savings 366020 185.00
Transit#: 322172739
_— 23125174 Issue Check Wizz,
Transit#:

ADP Enterprise HR screen print as of: 04/18/2022 12:43 PM