STAMPED & REDACTED REGINA JUAREZ_ 2302100.PDF
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Me nek dane Maricopa County soo) ah Human Resources Memo To: Juanita Garza, Clerk of the Board From: Lisa DaRosa Date: January 21, 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__ Lisa D at x 6-2406_ 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: al Duplicate or C 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. Regina Juarez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about __ 94/28/2021 (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 $. 186.25 (3) Signed: C —_——a ) . (4) Note: Please attach a coy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. A at day of _Cchobrr_29 a/. (5) Subscribed and sworn to before me this WZ) Madan TARY PUBLIC My commission expires: Novem ber 7, BOA Warrant/Check Number = 19399100 (if known) (6) Original Date of Issue 04/28/2021 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll O For Services or Goods furnished O Treasurer's refund/payment 01/21/2022 O Other: - Revised April 2015 ( Paycheck View Name Juarez,Regina A Confirmed Check# Issue Date Earnings Taxes Deductions Net Pay 2302100 04/28/2021 207.76 21.51 186.25 - Regular and Overtime Earnings Taxes RegHours RegPay = OT Hours OT Pay FED SSDisMLVEE 12.89 FED MedicareEE 3.01 * FED SS/Dis ER 12.89 * FED MedicareER 3.01 AZ Withholdng 5.61 r OtherEarnings r Deductions Code Hours Amounts Add to Gross| VAC 9.25 207.76 Y ADP Enterprise HR screen print as of: 07/01/2021 03:43 PM