STAMPED & REDACTED SERGIO LIZARRAGA.PDF

Maricopa County
Human Resources

Memo coe

To: Juanita Garza, Clerk of the Board PR U8 2022

From: Monica Reyes CLERK BOARD OI
Date: April 18, 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: Duplicate or LJ 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.
Sergio Lizarraga (1), being first sworn, upon oath deposes and says:

Name/Claimant

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 ed to hitmher in the sum of $ 1,620.65 .(3)

Signed: |Z (4)

@” 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 IZ day of Prt 2022.

NOTARY PUBLIC

» EILEEN WILLIAMS-PREAS
| Notary Public - State of Arizona
My commission expires: MARICOPA COUNTY
U-G ~aAnDS- Expires November 9, 2022 (seal)
Warrant/Check Number
(it known) (6) 23125161
Original Date of Issue
ate of Is 4/13/2022
Reason for original issue of Warrant/Check (8):
ml Payroll
1 For Services or Goods furnished
1 Treasurer’s refund/payment 04/18/2022

O Other: :

Revised April 2015

( Paycheck View iE

Name Lizarraga,Sergio L Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23125161 04/13/2022 1,930.82 187.86 122.31 1,620.65
-Regularand Overtine Eamings ~ Taxes — aaa
RegHours Reg Pay OTHours OT Pay FED SSDisMLVEE
FED MedicareEE
29.75 753.87 * FED SS/Dis ER
12.25 310.41 * FED MedicareER
AZ Withholdng
r OtherEarnings - Deductions
Code Hours Amounts Add to Gross 81 After-Tax
SCK 3.50 88.69 Y 43P Before-Tax
VAC 6.75 171.05 Y 70 Before-Tax
BRV 16.00 405.44 Y * 43PER Nontaxable
LWO 7.75 N * 52ER Nontaxable

ADP Enterprise HR screen print as of: 04/18/2022 09:20 AM