STAMPED & REDACTED DANIELLE NAVARRETTE.PDF

Maricopa County
Human Resources

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To: Juanita Garza, Clerk of the Board :
From: Monica Reyes

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: Duplicate or C 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.
Danielle Navarrette (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 $ 1336.05 (3)

signed\\ Oonll \ \Oa SS (4)
SS

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 “| sworn to before me this _-2.2) day of AdA \ QR,

NOTARY PUBLI

RENEE M HERNANDEZ
Notary Public, State of Arizona
Maricopa County
Commission # 552816

My Commission Expires
V August 20, 2022 (seal)

My commission expires:
Pndust 26, D035

Warrant/Check Number
(if known) (6) 23125188

Original Date of Issue 4/13/2022

(if known) (7) _

Reason for original issue of Warrant/Check (8):
Payroll
(1 For Services or Goods furnished
1 04/22/2022
1 Treasurer's refund/payment =
O

Other:

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

( Paycheck View

Name Navarrette,Danielle K Confirmed Check
Checka Issue Date Earnings Taxes Deductions Net Pay
23125188 04/13/2022 1,640.00 158.95 145.00 1,336.05
~ Regularand OvertimeEamings-—] jy Taxes ne —_
RegHours  RegPay  OTHours —_—OT Pay FED SSDisMLVEE 93.30
FED MedicareEE 21.81
40.00 820.00 FED Withholdng 16.75
40.00 820.00 * FED SS/Dis ER 93.30)
| * FED MedicareER 21.81
r OtherEarnings - + Deductions —
Code Hours Amounts Add to Gross 82 After-Tax 9.77
44 Before-Tax 121.64
50 Before-Tax 1.95
69 Before-Tax 11.64
* A4ER Nontaxable 804.62

ADP Enterprise HR screen print as of: 04/22/2022 11:21 AM