STAMPED & REDACTED CLAUDIA L. SAMANO.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 26 2029

CLERK BOAR

1 Non. D Bur - fF | 02/25/2015

Replacement Lost Warrant Form

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: Bi 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.
‘ Cal
( A Qudia \ « OOCHOANO(1), being first sworn, upon oath deposes and says:
ame/Claiman'
On or about (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 $ { i . \o (3)

Signed: [ Noudsa pL amavo (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 19 hay of Nor \ 20 22.

Ta wln Donn 2s

NOTARY PUBLIC

Notary Public State of Arizona
Maricopa County

commission expires; Paula Ann Bal
ar best, if Fn My Commninson Expres 1/01/2028 (seal)

Commission Number 571476
Warrant/Check Number
: known) (6) OO 23 | 352 4 O

Original Date of Issue OWS 1>/ 2099

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

O For Services or Goods furnished j 04/21/2022

1 Treasurer’s refund/payment ___.
QO Other:

Revised April 2015 A.R.S. 11-632 & 11-644

( Paycheck View

Name Samano,Claudia L Confirmed Check |
Check# Issue Date Earnings Taxes Deductions Net Pay
23125230 04/13/2022 1,719.65 288.07 263.46 1,168.12
‘Regular and Overtime Earnings 5 + Taxes
RegHours —_ Reg Pay OTHours OT Pay FED SSDisMLVEE 103.61
FED MedicareEE 24.23
40.00 844.00 | FED Withholdng 107.64
40.00 844.00 * FED SS/Dis ER 103.61
* FED MedicareER 24.23
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 92 After-Tax 1.47
OTP 0.75 23.74 Y 14 After-Tax 3.27
OTP 0.25 7.91 Y 44 Before-Tax 41.67
50 Before-Tax 1.09
69 Before-Tax 5.82

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