STAMPED & REDACTED SAMUEL PAVLISICK.PDF

Maricopa County
Human Resources

Vemo

To: Juanita Garza, Clerk of the Board
From: Daniel Villalba
Date: April 21, 2022
Re: Replacement of Lost Payroll Warrants Hees eff

VISORS

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 Daniel 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 4 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Duplicate or OO Sstale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form carrespond fo numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

‘ev Lisicke Srmnnod (1), being first sworn, upon oath deposes and says:
Name/Claimant 7 .

On or about oy | Ke) { LOL (date)(2) a warrant/check was issued to the

above named nerson/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 be \ssued to him/her i in the sum of $ (NS Nd (3)

sn Peewee,

> (4)
Leann

Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

Signed:

(5) Subscribed and sworn to before me this Zh day of _# pri { 20_272.

Jv, (Pr~__ ty bcn04

NOTARY PUBLIC
a . ANA OCHOA
My commission expires: Notary Publle - State of Arizona
5/5 0/073 caine (ea)
xpires May 30,
Warrant/Check Number
‘if known) (6) 23125197
Original Date of Issue
(if known) (7) 04/13/2022

Reason for original Issue of Warrant/Check (8):
Payroll
C For Services or Goods furnished
04/21/2022
1 Treasurer's refund/payment =

1 Other:

Revised April 2015 ARS, 11-632 & 11-644

( Paycheck View

Name Pavlisick,Samuel J Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay
23125197 04/13/2022 2,339.77 356.34 546.74 1,436.69
- Regular and Overtime Earnings Taxes
RegHours — Reg Pay OT Hours OT Pay FED SSDisMLVEE 133.75
FED MedicareEE 31.28
47.00 4324.93 FED Withholdng 142.25
33.00 930.27 * FED SS/Dis ER 133.75:
* FED MedicareER 31.28)
- OtherEarnings r Deductions
Code Hours Amounts Add to Gross 167 After-Tax 13.84
OTP 2.00 84.57 Y 91A After-Tax 2.95
92 After-Tax 6.79
98B After-Tax 0.50
100 Before-Tax 150.00

ADP Enterprise HR screen print as of: 04/21/2022 12:37 PM