STAMPED & REDACTED BRANDON PARZ.PDF

Maricopa County
Human Resources

(Me
Memo eit

To: Juanita Garza, Clerk of the Board iS

From: Monica Reyes nN
Date: April 22, 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.

Replacement Lost Warrant Form 1 02/25/2015

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

This application is for: © puplicate or CI 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.
Brandon Parz (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 94/1 3/2022 (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 ,696.54 (3)
Signed: 2 (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_272 day of Apr 20 22.
Cum Wdimr-Puar

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS

My commission expires: Notary Pubic - State of Arizona

W~ 4 2022. MicoPACOUNTY | (seal
Expires November 9, 2022
Warrant/Check Number
(if known) (6) 23125196
Original Date of Issue
(if known) (7) 04/13/2022

Reasan for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished
C1 Treasurer's refund/payment Cees

OO Other:

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

( Paycheck View

Name Parz,Brandon J Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23125196 04/13/2022 1,976.72 280.18 1,696.54
Regularand Overtime Earnings ee - Taxes ~~
Reg Hours Reg Pay OT Hours OT Pay — FED SSDisMLVEE
FED MedicareEE
40.00 967.20 FED Withholdng
40.00 967.20 * FED SS/Dis ER
* FED MedicareER
- OtherEarnings - Deductions
Code Hours Amounts Add to Gross * 57 Nontaxable
AWP 1.75 42.32 Y * 90ER Nontaxable
* 91ER Nontaxable
* 90GTL Taxable

ADP Enterprise HR screen print as of: 04/22/2022 11:26 AM