STAMPED & REDACTED DANIELLE NAVARRETTE .PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes

Date: April/?, 2022 GSAIso3y
Hod Dol Lead. AL

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.
McS0 - Dx0

Replacement Lost Warrant Form 4 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: O 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.
Danielle Navarrette (1), being first sworn, upon oath deposes and says:
ame/Claiman'
On or about __ 3/30/22 (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 $ 1258.99 (3)

Signed: QOamsich\ osallts (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 3 day of Apis Q 2022.

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
Notary Public - State of Arizona
MARICOPA COUNTY (sdal)
Commission # 554349
Expires Novernber 9, 2022

My commission expires: EN,

[\-4..029

Warrant/Check Number
(if known) (6) 23122142

Original Date of Issue
(if known) (7) 3/30/22

Reason for original issue of Warrant/Check (8): 04/14/2022
Payroll -

C1 For Services or Goods furnished.
QO Treasurer’s refund/payment
O Other:

i > a
Revised April 2015 Mou ARS. 11-632 & 11-644

Name Navarrette,Danielle K Confirmed Check |
Check# Issue Date Earnings Taxes Deductions Net Pay |
23122142 03/30/2022 1,641.75 151.56 231.20 1,258.99
~Regularand Overtime Earnings ——— ~ Taxes ~ -
RegHours RegPay OT Hours OT Pay FED SSDisMLVEE 91.16
FED MedicareEE 21.32
40.00 820.00 FED Withholdng 12.61
40.00 a * FED SS/Dis ER 91.16
* FED MedicareER 21.32
r OtherEarnings —_ r Deductions — —
Code Hours Amounts _ Add to Gross} 147 After-Tax 50.00
SH1 3.50 4.75 Y 82 After-Tax 9.77
44 Before-Tax 43.40 |
50 Before-Tax 0.66 |
69 Before-Tax 2.37 |

ADP Enterprise HR screen print as of: 04/08/2022 08:50 AM