STAMPED & REDACTED GINA M. SCHNIEDER.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: April 21, 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, Suite 400.

Stale Dated Warrant Duplicate Warrant

Thank you.
RECEIVED

APR 20 2022
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

th. Toler AE

Replacement Lost Warrant Form 02/25/2015

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

This application is for: al 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.
Gina M. Schneider (1), being first sworn, upon oath deposes and says:
On or about 94/13/2022 (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 $ 1079.37 (3)
Signed: a Ff \O- . (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 20M day of ip nl 2022,

ina _Cabud

NOTARY PUBLIC
TRINA COLBERT
. oe : Notary Public - State of Arizona
My commission expires: MARICOPA COUNTY
la / t / 20a2 Expres December 1, 2023 (seal)
Warrant/Check Number
(it known) (6) 0023125234
Original Date of Issue
(if known) (7) 4/13/2022
Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished.
04/21/2022

(1 Treasurer’s refund/payment
O Other:

Revised April 2015 PRD 11092 & LETUTT

( Paycheck View

Name Schneider,Gina M Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23125234 04/13/2022 1,558.16 285.42 193.37 1,079.37
Regular and Overtine Earnings ~Taxes -
Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLVEE 96.61
FED MedicareEE 22.59)
40.00 762.40 FED Withholdng 96.46
40.00 762.40 * FED SS/Dis ER 96.61
* FED MedicareER 22.59
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.96
AWP 1.75 33.36 Y 12 Before-Tax 190.41
* 57 Nontaxable 16.04
* 90ER Nontaxable 0.60
* 91ER Nontaxable 0.30

ADP Enterprise HR screen print as of: 04/21/2022 12:40 PM