STAMPED & REDACTED LAYLA GABIR.PDF

Maricopa County
Human Resources

Viemo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: February 23, 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 x 6-8051_ for any questions. Please
route approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant (Over 1 Year) [ Duplicate Warrant

Thank you.

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: (ml Duplicate or C 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.

Layla Gabir (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 02/16/2022 (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 $¢ 849.93 (3)
Signed: t= (4)
wv ae

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_22 day of Feo 2022.

NOTARY PUBLIC

we . EILEEN WILLIAMS-PREAS
My commission expires: Notary Pubic - State of fvizona
LL -cy- 2022 Heong 284340 (seal)

Expires November 9, 2022

Warrant/Check Number |
(if known) (6) 23112585

Original Date of Issue
(if known) (7) 2/16/2022

Reason for original issue of Warrant/Check (8):
A Payroll 02/23/2022

O For Services or Goods furnished
1 Treasurer's refund/payment
O Other:

Revised April 2015 Pic > 46D ~ Ole -0344

Up A.R.S, 11-632 & 11-644

( Paycheck View

Name Gabir,Layla M Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23112585 02/16/2022 1,216.00 205.53 160.54 849.93
~ Regularand Overtime Earnings
RegHours — Reg Pay OT Hours OT Pay SSDisMLVEE 74.82
MedicareEE 17.50
* FED SS/Dis ER 74.82
* FED MedicareER 17.50
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.31

50 Before-Tax 0.66
61 Before-Tax 8.97
12 Before-Tax 148.60
* 5OER Nontaxable 2.74

ADP Enterprise HR screen print as of: 02/23/2022 10:04 AM