STAMPED & REDACTED STEPHEN A. PEREZ.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: fl Duplicate or CO 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.
Stephen A. Perez (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about _ 4/13/22 (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 $ 1,543.81 .(3)

Signed: Se xe (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 Oy this _ 18 day of Apr 2022. .

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 564349

Expires November 9, 2022 (seal)

My commission expires:

W-A-BO2a

Warrant/Check Number
(if known) (6) 23125199

Original Date of Issue 4/13/2022

(if known) (7)

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

For Services or Goods furnished 04/18/2022

o
C1 Treasurer’s refund/payment
O Other:

Revised April 2015 OS ( _ M29 — \2 2°. ARS, 11-632 & 11-644

Gr picenp

( Paycheck View

Name Perez,Stephen A Confirmed Check |
Check# Issue Date Earnings Taxes Deductions Net Pay |
23125199 04/13/2022 1,835.13 291.32 1,543.81 |
~ Regularand Overtime! Eamings ee, ~Taxes oe ,
RegHours  RegPay — OT Hours OT Pay _ FED SSDisMLVEE 113.78
FED MedicareEE 26.61
40.00 391.20 FED Withholdng 84.87
40.00 891.20 * FED SS/Dis ER 113.78
| * FED MedicareER 26.61
» thar Sang =e r Deductions
Code Hours __ Amounts Add to Gross * 57 Nontaxable 16.04
OTP 0.25 8.36 Y * 90ER Nontaxable 0.71
SH1 5.00 2.50 Y * 91ER Nontaxable 0.35
AWP 1.75 38.99 Y
SH1 5.75 2.88 Y

ADP Enterprise HR screen print as of: 04/18/2022 12:01 PM