STAMPED & REDACTED ADRIAN J TRUJILLO.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Daniel Villalba (Payroll Specialist)
Date: March 2, 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 Daniel. at ext. 62406 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

Affidavit/Claim Form P2FER EL Pi

This application is for: = Duplicate or C1 state-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.
Adrian J. Trujillo (1), being first sworn, upon oath deposes.and says:
On or about 02/1 6/2022 (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 MILD in the sum of $460.62 (3)
Signed: \ (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 Ql aay of —Fetocuasy 20.252
o>

NOTARY PUBLIC

> L. GITTENS —
fe), Notary Public - State of Arizona
B Bermisson #200220
y Commission #
Explres.June 02, 2026 (seal)

My commission expires:

Ob-Oo- S63S—

| Warrant/Check Number
(if known).(6) 231 1 2689

Original Date of Issue 02/16/2022

(if known) (7)

Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished 03/02/2022

 Treasurer’s refund/payment
O Other:

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S, 11-632 & 11-644

( Paycheck View | MC’

Earnin

Name Trujillo,Adrian J

Check# Issue Date Earnings
23112689 02/16/2022 760.00
~ Regularand Overtime Earnings
RegHours __ Reg Pay OT Hours OT Pay
40.00 760.00
- OtherEarnings ~~
Code Hours 7 Amounts Add to Gross!

Confirmed Check
Taxes Deductions Net Pay
79.76 219.62 460.62
-Taxes _——
FED SSDisMLVEE 41.09
FED MedicareEE 9.61
* FED SS/Dis ER 41.09
* FED MedicareER 9.61
AZ Withholdng 29.06)
- Deductions — _ ~
92 After-Tax 28.00
14 After-Tax 1.44
44 Before-Tax 69.48
50 Before-Tax 1.09
63 Before-Tax 26.74

ADP Enterprise HR screen print as of: 03/02/2022 12:20 PM