STAMPED & REDACTED THOMAS F. SAUNDERS.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: February 25, 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: [i] Duplicate or L] 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.
Thomas F Saunders (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 92/02/2022 (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 $ 583.64 (3)

Signed: i Zz aE (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 Qu day of Fe a 20 2Z.
NOTARY PUBLIC
EILEEN WILLIAMS-PREAS
My commission expires: NORPARIGOPAGOUNTY
WHC + 205-2. Ne one 82022 (seal)
Warrant/Check Number
(if known) (6) 231 09628
Original Date of Issue
ate os 02/02/2022
Reason for original issue of Warrant/Check (8°
Payroll
C1 For Services or Goods furnished 02/25/2022
1 Treasurer’s refund/payment : =
OO Other:

Revised April 2015

( Paycheck View

Name Saunders, Thomas F Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23109628 02/02/2022 776.00 96.06 96.30 583.64
~ Regular and Overtime Earnings - Taxes -
Reg Hours Reg Pay OTHours _—OT Pay FED SSDisMLVEE 48.11
FED MedicareEE 11.25
32.00 776.00 FED Withholdng 18.31
* FED SS/Dis ER 48.11
* FED MedicareER 11.25
r OtherEarnings r Deductions
Code _ Hours Amounts Add to Gross 14 After-Tax 1.47
12 Before-Tax 94.83
* 12 Nontaxable 94.83
* 14 Nontaxable 1.47

ADP Enterprise HR screen print as of: 02/23/2022 10:00 AM