STAMPED & REDACTED LORISSA HUBBARD.PDF

Maricopa County
Human Resources

VMemo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: February 15, 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: 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.
Lorissa Hubbard (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

warran 2 of $ 932.56 3)
Signed? (4)

e attach a copy of the warrant/check if available and/or any other
eviderice that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this _15 day of _ Fe fo 20 22.

Gen Wine re ck

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
Notary Publis - State of Arizona
MARICOPA COUNTY
Commission # 854349
Expires November 8, 2022

My commission expires:
N=. 30aa.

(seal)
warentmoanye) 23109558
Original ate or one 2 12 12022
Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished 02/16/2022

O Treasurer's refund/payment
1 Other:

Revised April 2015 ¥ (eo2- SO 7 4 ar A.RS. 11-632 & 11-644

( ayehenk Vea / MC /-E

Name Hubbard,Lorissa L Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23109558 02/02/2022 1,266.95 177.16 157.23 932.56
~ Regular and Overtime Earnings - — ~ Taxes —
RegHours Reg Pay OT Hours OT Pay FED SSDisMLVEE 78.55
FED MedicareEE 18.37
40.00 690.80 FED Withholdng 65.78
20.75 358.35 _* FED SS/Dis ER 78.55
* FED MedicareER 18.37
r OtherEarnings — — - Deductions— _ : a
Code Hours Amounts Add to Gross 14 After-Tax 2.41
HPA 8.00 138.16 Y 12 Before-Tax 154.82
MA2 5.00 5.75 Y * 42 Nontaxable 154.82
MA3 15.75 30.71 Y * 14 Nontaxable 2.41
SCK 1.00 17.27 Y

ADP Enterprise HR screen print as of: 02/15/2022 10:21 AM