STAMPED & REDACTED CYNTHIA MONTENEGRO (2).PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: April 26, 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
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Replacement Lost Warrant Form

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: 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.
Cynthia Montenegro (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

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warrant/check be issued to him/her in the sum of $ 1 31649 \ Z \o. Yq (3)

Signed: [patie Mockres vo (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 ao day of Ay. 20 aa.
WwW) eee)
NOTARY PUBLIC

My comma expires:
12-200

EILEEN WILLIAMS-PREAS
Notary Pubtic - State of Arizona
MARICOPA GOUNTY
Commission # 554349 (seq
Expires November 9, 2022

oS

Warrant/Check Number
(if known) (6) 23125182

(if. known) (7)

Reason for original issue of Warrant/Check (8):
ml Payroll 04/27/2022

C1 For Services or Goods furnished

O Treasurer’s refund/payment

0 Other: :
toy pIcizup
Revised April 2015 U8) 2-— WYA> Slo 98) ARS. 11-632 & 11-644

- Montenegro, Cynthia D Company: MC1 Off Cycle: N
MC - Maricopa County _ PayGroup: NEX Separate Check # 0
5059 - MASH _ Petiod End 04/03/2022 Reprint: N
NEX-NonExempt Page 636 Adjustment: N
Active 03/07/2022 Reg/FT / Lines 5

- Montenegro,Cynthia D - MC1/NEX

f Paycheck View f MCY-Earnings { Taxes | Deductions { Gamishments | Special Accumulators Distributions

Name Montenegro,Cynthia D Confirmed Check and Advice
Check# Issue Date Earnings Taxes Deductions Net Pay
23125182 04/13/2022 1,698.73 171.42 210.82 1,316.49
Check/Advice# Type Account# Amount (cal
3649426 Checking 183720028 100.00
Transit#: 122100024
23125182 Issue Check 1,216.49 |
Transit#:

ADP Enterprise HR screen print as of: 04/25/2022 08:41 AM