STAMPED & REDACTED VERONICA MIDGETT .PDF

Maricopa County
Human Resources

VMemo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: April 28, 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

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: i 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.
Veronica Midget (1), being first sworn, upon oath deposes and says:
ame/Claiman'
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 $966.45 (3)
Signed: Veronica Midgett CEeau A ZF (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 28th day of April 2022.

Cute Uline

NOTARY PUBLIC

EILEEN WILLIAMS-P| 1
Nola Pubic- Stearn

My commission expires: MARICOPA COUNTY
i) Q- Boar. Expites November 8: aa2 (seal)
=
Warrant/Check Number QBlIS INS
(if known) (6)
Original Date of Issue “ :
(if known) (7) Hf | | 2) 22.
Reason for original issue of Warrant/Check (8):
fm Payroll
© For Services or Goods furnished
Treasurer's refund/payment 04/29/2022
O Other: -

Revised April 2015

( Paycheck View

Confirmed

Name Midgett,Veronica E Check |
Check# Issue Date Earnings Taxes Deductions Net Pay |
23125175 04/13/2022 1,376.00 181.35 228.20 SARS |
‘Regular and Overtime Earnings ~~ a > Taxes ~~ — a 1
RegHours _ RegPay _ OTHours_ OT Pay FED SSDisMLVEE 82.02
FED MedicareEE 19.18
40.00 680.00 FED Withholdng 70.91
40.00 680.00 _* FED SS/Dis ER 82.02
| * FED MedicareER 19.18
- OtherEarnings. - . Deductions -
Code Hours Amounts Add to Gross 91A After-Tax 1.80
SED 8.00 8.00 Y 92 After-Tax 2.61
SED 8.00 8.00 Y 14 After-Tax 2.61
44 Before-Tax 43.40
50 Before-Tax

0.66

ADP Enterprise HR screen print as of: 04/28/2022 11:14 AM