STAMPED & REDACTED CACEY A. VILLA.PDF

mOMARIGOPA COURT Y - Maricopa County
12) FEB <3. PHI? [1 Human Resources
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Memo

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

Date: February 3, 2022

Re: Lost Check

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 800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

AFFIDAVIT/NOTICE OF CLAIM 7 02/02/2022

STATE OF ARIZONA
COUNTY OF MARICOPA
Caceu \illa BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:
That on the ip ~) m day of A ( A \ \ \ } (\ ry » 20 44. , he/she presented

to Maricopa County, for payment a claim for services rendered or supplies furnished during the

month of |
s in Vin, i ainn nivic aliriye (A .
five nunady ed Huienty ning dollars 8 joe

, said claim being in the sum of

Dollars ($ i) 29 ‘ a) \ ) in payment of which the Board of Supervisors caused the

Warrant No. 2.2/06G4, by to be issued on _,| (A Hay \ 59 20 2‘ _, drawn on the
Payroll Clearing Account fund.

Affiant further says that although he/she was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost. Under penalty of

perjury, affiant hereby affirms that this claim is correct and the amount shown is due and owing.

WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said

Warrant No. OalOlo9S Inthe sumof$__0 1A % 0 \
Wy 2 —
Dated: O4+-}2A 2022 Signed: (CUCZY VISTA fon
f ‘Affiant/

*** A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the
replacement check.***

Subscribed and sworn to before me this 2 day of Taste » 0B

Notary Public

My commission expires: £27-¢#3 — THOMAS D. WILKIE
Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 597426
Expires February 8, 2025

UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO: { ‘Seu’

Name: : Telephone Number:
Address: Employee ID #:
Address:

01/31/2013

( Paycheck View

Name Villa,Cacey A Confirmed Check |

Check# Issue Date Earnings Taxes Deductions Net Pay
23106695 01/19/2022 700.00 83.32 86.87 529.81
“Regularand Overtime Earnings ———--—-— - — r Taxes - :

RegHours  RegPay  OTHours OT Pay _ | 7 nes ee

FED MedicareEE 10.15)

40.00 700.00 | FED Withholdng 13.18

_* FED SS/Dis ER 43.40

oo * FED MedicareER 10.15

Code _ Hours __ Amounts Add to Gross; ; 14 After-Tax 1.33

12 Before-Tax 85.54

| * 12 Nontaxable 85.54

414 Nontaxable 1.33

ADP Enterprise HR screen print as of: 02/03/2022 12:06 PM

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