STAMPED & REDACTED VIRGINIA JOHNSON.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board RECEIVED
From: Daniel Villalba

Date: February 7, 2022 CLERK BOARD OF SU
Peal Dolien - AL

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. : oy)
Stale Dated Warrant -_ Duplicate Warrant

Thank you. _ >»

——... ml

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: i 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.

Vi ray aTdohnsan (1), being first sworn, upon oath deposes and says:
Namé/Zlaimant

On or about }- 23-92. (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 $ 1,041.9 Le (3)

Signed: Ne Chaco (a

Note. pleas$-ath Jy a copy of the warlsmt/eck if available and/or any other
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this___]_ _day of _f-elo 20.22.
\ ‘ .
NOTARY PUBLIC [ Zit, EILEEN WILLIAMS PREAS
Notary Public - State of Arizona
MARICOPA GOUNTY
Commission # 554349
Expires November 9, 2022

My commission expires:
\V-OF- 903.d.

(seal)

Warrant/Check Number

(if known) (6) 232109563

Original Date of Issue

(if known) (7) 22 Qed)

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

AL Payroll

O For Services or Goods furnished
02/08/2022

O Treasurer’s refund/payment
O Other:

Revised April 2015

Paycheck View

Name Johnson, Virginia Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay
23109563 02/02/2022 1,516.00 265.90 188.14 1,061.96
Regular and Overtime Earnings > Taxes
RegHours RegPay = OTHours OT Pay | FED SSDisMLVEE 93.99
FED MedicareEE 21.98
40.00 758.00 FED Withholdng 102.02
31.75 601.66 _* FED SS/Dis ER 93.99
| * FED MedicareER 21.98
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.88
HPA 8.00 151.60 Y | {2 Before-Tax 185.26
VAC 0.25 4.74 Y * 42 Nontaxable 185.26
* 44 Nontaxable 2.88

ADP Enterprise HR screen print as of: 02/07/2022 04:16 PM