STAMPED & REDACTED SOYENIXE LOPEZ.PDF

Maricopa County

Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: May 4, 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: 4 oupteat or LI 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.
Soyen!| LOG Lopez (1), being first sworn, upon oath deposes and says:
~~ Name/Claimant iu
On or about 4/13] 4a (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 $ 3, ad q 44 (3)
Signed: (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 Wncuy,_day of \ 2022.

NOTARY PUBLIC

My commission expires:

Zine U (seal)
Warrant/Check Number | 43125163
(if known) (8)
Original Date of Issue 04/13/2022
(it known) (7)
Reasgn for original: issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished
C1 Treasurer's refund/payment
1 Other: 05/05/2022

_ Revised Apel-2015

Check

Name Lopez,Soyenixe G Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay
23125163 04/13/2022 4,747.87 1,409.63 113.45 3,224.79
~ Regular and Overtime Earnings _ ~ r Taxes as
RegHours  RegPay  OTHours OT Pay FED SSDisMLVEE 294.37
FED MedicareEE 68.84
20.00 521.00 FED Withholdng 920.97
12.00 312.60 * FED SS/Dis ER 294.37
* FED MedicareER 68.84
r Other Earnings - Deductions .
Code Hours Amounts Add to Gross 160 After-Tax 10.00
LVN 150.26 3914.27 Y 14 After-Tax 1.58
12 Before-Tax 101.87
* 42 Nontaxable 101.87
* 414 Nontaxable 1.58

ADP Enterprise HR screen print as of: 05/04/2022 12:28 PM