STAMPED & REDACTED MARTA DELONE.PDF
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Maricopa County Human Resources To: Juanita Garza, Clerk of the Board J = From: Monica Reyes f a Date: March 9, 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 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. Marta DeLeon (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 3/2/2022 (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 be issued to him/her in the sum of $1 1274.92 (3) Signed: Matti Ld re (4) v Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. nt we SCr and sworn to before me this O i. day of March 20 2D NOTARY PUBLIC__) RENEE M HERNANDEZ Notary Public, State of Arizona Maricopa County Commission # 552816 My Commission Expires August 20, 2022 (seal) My commission expires: + 22, 3222 v Warrant/Check Number (it known) (6) 23115769 Original Date of Issue (if known) (7) 3/2/2022 Reason for original issue of Warrant/Check (8): i Payroll C1 For Services or Goods furnished OO Treasurer’s refund/payment 03/10/2022 C1 Other: = Revised April 2015 ( Paycheck View Name DeLeon,Marta Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23115769 03/02/2022 1,708.96 221.95 212.09 1,274.92 Regular and Overtime Earnings Taxes — RegHours RegPay OT Hours OTPay | FED SSDisMLVEE 105.96 FED MedicareEE 24.78 40.00 848.00 FED Withholdng 79.21 40.00 848.00 * FED SS/Dis ER 105.96 * FED MedicareER 24.78 r OtherEarnings r Deductions Code Hours Amounts Add to Gross 14 After-Tax 3.25 SH1 5.00 2.50 Y 12 Before-Tax 208.84 OTP 0.25 7.96 Y * 12 Nontaxable 208.84 SH1 5.00 2.50 Y * 14 Nontaxable 3.25 ADP Enterprise HR screen print as of: 03/09/2022 10:02 AM