STAMPED & REDACTED REGINA JUAREZ_ 2302103.PDF
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BORRRICOPA COUNTY Maricopa County 522 JAN 21 AP IG: 14 Human Resources 2022 JAR CG) ATi ie Nead NeViueae AA 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: 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. Regina Juarez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 4/28/21 (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 $ 119.77 (3) Signed: ae ? ee ) (4) Ta a 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 before me this OF?” day of Octther _ 20 2. Z. gee 0 here Le Y PUBLIC ( ly commission expires: Novemad? 7 2 1078 Warrant/Check Number (if known) (6) 2302103 Original Date of Issue (if known) (7) 04/28/21 Reason for original issue of Warrant/Check (8): Payroll C1 For Services or Goods furnished O Treasurer’s refund/payment O Other: : == 01/21/2022 Revised April 2015 Paycheck View Name Juarez,Regina A Confirmed Check# Issue Date Earnings Taxes Deductions Net Pay 2302103 04/28/2021 207.75 17.60 70.38 119.77 r Regular and Overtime Earnings > Taxes RegHours — Reg Pay OT Hours OT Pay FED SSDisMLVEE 10.54 FED MedicareEE 2.47 * FED SS/Dis ER 10.54 * FED MedicareER 2.47 AZ Withholdng 4.59 r OtherEarnings r Deductions Code Hours Amounts Add to Gross, 82 After-Tax 10.71 VAC 9.25 207.75 Y 91A After-Tax 2.35 92 After-Tax 19.62 43P Before-Tax 54.85 50 Before-Tax 0.66 \ ~ Ss ADP Enterprise HR screen print as of: 07/01/2021 03:42 PM & %