STAMPED & REDACTED DERIK STEVEN RODGERS .PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Daniel Villalba
Date: April 29, 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 Daniel. at ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

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 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.
Derik Steven Rodgers (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 3/30/2022 (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 g951 15 .(3)

Signed: rel QR eolp2— (4)

oF

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 27h day ofl? 1 2072
NOTARY PUBLIC
My commission expires:
QC -~2GE (seal)
Warrant/Check Number
(if known) (6) 25111 p
Original Date of Issue
(if known) (7) 3130[22
Reason for original issue of Warrant/Check (8):
Payroll
CO For Services or Goods furnished
C1 Treasurer’s refund/payment
» 04/29/2022

[1 Other:

Revised April 2015

( Paycheck View

Name Rodgers,Derik S

Confirmed Check
Check# Issue Date Eamings Taxes Deductions Net Pay |
23122165 03/30/2022 728.80 87.20 90.45 551.15 |
r Regularand Overtime Earnings ~ a — - :
RegHours —_ Reg Pay OT Hours OT Pay SSDisMLVEE
MedicareEE
40.00 728,80 FED Withholdng
* FED SS/Dis ER
* FED MedicareER
r OtherEarnings 7 r Deductions
Code _ Hours Amounts Add to Gross, 14 After-Tax
12 Before-Tax
* 12 Nontaxable
* 14 Nontaxable

ADP Enterprise HR screen print as of: 04/29/2022 12:01 PM