STAMPED & REDACTED STACY HALLOWAY.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board APR 07 2022
Date: April 7, 2022 Lad Dore AE
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.

* Devo

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: 1 puplicate 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.
allou4 (1), being first sworn, upon oath deposes and says:
~Name/Claiant ad
On or about Mowe 20,A022 (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 $ Ly OVA. 26 (3)
fp (4)

Note: Pleas€ attach 1) of: the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

Signed:

(5) Subscribed and sworn to before me this ik day of Beori \ 20A2.

Nonm 0: Vermeer

NOTARY PUBLIC

GEER DIANA D RAMACHER,
Notary Public - Arizona

Pr . . Maricopa County
My commission expires: Commission # 557220

N\ecom her l, iy) 027 SH” My Comm. Expires Dec 1, 2022 (seal)

Warrant/Check Number a \ .
(if known) (6) 2 A\oo OGle

Original Date of Issue 2)\ 2b \ Vo

(if known) (7)

Reason for original issue of Warrant/Check (8):
ip Payroll

0 For Services or Goods furnished
0 Treasurer’s refund/payment 04/07/2022
O Other: -

Revised April 2015

( Paycheck View

Name Holloway Stacy D Confirmed Check

Check# Issue Date Earnings Taxes Deductions
23122096 03/30/2022 1,491.20 213.94 185.06
~ Regularand Overtime Eamings —— : Taxes SS
Reg Hours _Reg Pay OT Hours 7 OT Pay ' FED SSDisMLVEE
FED MedicareEE
40.00 745.60 FED Withholdng
40.00 745.60 la FED $S/Dis ER
* FED MedicareER
Code Hours _ Amounts Add to Gross 14 After-Tax 2.83
12 Before-Tax 182.23
® 4D Nontaxable 182.23
* 44 Nontaxable 2.83

ADP Enterprise HR screen print as of: 04/07/2022 10:38 AM