STAMPED & REDACTED BRANDON DUNLAP.PDF

MARICOPA Courne’ Maricopa County
SEER <a Bl bens Human Resources

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To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: February 8, 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 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.
Brandon Dunlap (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 2/2/2022 (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 $ 1,484.18 (3)

signed: SX#_S) (4)

i
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 befo;

Romee dA Vernandee

NOTARY PUBLIC

BS» day of February 2022.

ERNANDEZ |
No ENE A Hee of me |

My commission expires:
Arnapast 90, 303.0,

Maricopa Coun. 6
Commission # 55281 a
My Commission Expires ; (seal)

August 20, 2022

Warrant/Check Number x
(if known) (6) 231 09536

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

Reason for original issue of Warrant/Check (8):
mm Payroll
C1 For Services or Goods furnished 02/10/2022

1 Treasurer’s refund/payment
O Other:

Revised April 2015 ARS, 11-632 & 11-644

1,484.1 8

Name Dunlap,Brandon C Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay |
23109536 02/02/2022 2,117.91 370.90 262.83
- Regularand Overtime Earnings ———————— Se
RegHours —_ Reg Pay OT Hours OT Pay SSDisMLVEE 131.31
MedicareEE 30.71
40.00 844.00 FED Withholdng 175.42
40.00 844.00 * FED SS/Dis ER 131.31
* FED MedicareER 30.71
cr OtherEamings a - r Deductions
Code Hours Amounts Add to Gross 14 After-Tax 4.02
OTP 4.00 126.60 Y 42 Before-Tax 258.81
AWP. 1.50 31.65 Y * 42 Nontaxable 258.81
HPA 8.00 168.80 Y * 14 Nontaxable 4.02
OTP 3.25 102.86 Y

ADP Enterprise HR screen print as of: 02/08/2022 02:12 PM