STAMPED & REDACTED REGINA JUAREZ_ 2302102.PDF

BOM ARICOPA COUNT Maricopa County
ong JAN 21 AMID: U4 Human Resources
dUce JAR C Ail 1s

Nenad Nev. tend Ua

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: ml 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 __ 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 $. 119.78 -(3)

Signed: SY (4)

Note. f/ease_attacthi 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 _<? vr day of Celtor 20_=7/,
(pug Jp ocltee

TARY PUBLIC

My commission expires:
WWengt (7, 20°O

=

| Warrant/Check Number
(if known) (6) 23021 02

Original Date of Issue
(if known) (7)

Reason for original issue of Warrant/Check (8):
Payroll

OO 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
Check# Issue Date Earnings Taxes Deductions Net Pay
2302102 04/28/2021 207.76 17.60 70.38 119.78
~ Regular and Overtime Earnings r 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 9.25 207.76 Y 91A After-Tax 2.35
92 Atter-Tax 19.62
43P Before-Tax 54.85
50 Before-Tax 0.66

ADP Enterprise HR screen print as of: 07/01/2021 03:43 PM