STAMPED & REDACTED JACQUELINE SANDOVAL.PDF

Maricopa County
Human Resources

To: Cindy Goelz, Clerk of the Board
From: Daniel Villalba
Date: February 3, 2022

Re: Replacement

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

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

—
This application is for: Duplicate or L] 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.

Aacnurlioe Sa nda iO (1), being first sworn, upon oath deposes and says:
Name/Claimant 12) 08 |202I Th.

On or about PEF | (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 $ AIS T1 (3)
Z fs /
Signed: “2174 (24 Leo. Bafouad (4)

Note: PleaSé 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 A { day of — Wave Petey 2022...

NOTARY PUBLIC

Notary Public - State of Arizona
MARICOPA COUNTY

My commission expires: Commission # 597426

L C2 - LE ED. AS Expires February 8, 2026 (seal)
Warrant/Check Number
(if known) (6) 6079934
Original Date of Issue : .
(if known) (7) | | CA 21
Reason for original issue of Warrant/Check (8):
cal Payroll
C1 For Services or Goods furnished
02/02/2022

C Treasurer’s refund/payment
1 Other:

Revised April 2015

( Paycheck View

Name Sandoval, Jacqueline Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23097924 12/08/2021 712.50 96.73 615.77
- Regular and Overtime Earnings
RegHours — Reg Pay OT Hours OT Pay SSDisMLVEE 44.18
MedicareEE 10.33
FED Withholdng 22.98
* FED SS/Dis ER 44.18
* FED MedicareER 10.33
 OtherEarnings r Deductions
Code Hours Amounts Add to Gross
STI 712.50 Y

ADP Enterprise HR screen print as of: 02/03/2022 12:05 PM