STAMPED & REDACTED ELOAH CRONIN.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes ‘9
Date: December 7, 2021 =
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 ___ Monica at x 6-8051__ for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.

Stale Dated Warrant (Over 1 Year) Duplicate Warrant

Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

y
This application is for: Dae Duplicate or Destale-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.

Eloah Cronin (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about Nov 10th 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 jgsued to him/her in the sum of ¢ 1417.79 (3)
“th (4)

Note. Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

Signed:

Soman sworn to before me this [SE day of December 202).

NOTARY\ PUBLIC

M ore a, eune saxidxy
ly comms ason & ress Uo|ss}wL0D
" SNALLIO "1
Warrant/Check Number 22 0AITAU
(if known) (6) “ :
Original Date of Issue [Lo |
(if known) (7) {O12
Reason for original issue of Warrant/Check (8):
Dx Payroll
1 For Services or Goods furnished 12/10/2021

1 Treasurer's refund/payment ’ =
OO Other:

HY

Revised April 2015

{ Paycheck View

Name Cronin,Eloah Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23091594 11/10/2021 1,862.62 217.40 227.43 1,417.79
r Regularand Overtime Earnings
RegHours RegPay = OT Hours OTPay _ SSDisMLVEE 113.63
MedicareEE 26.57
40.00 810.00 FED Withholdng 64.33)
40.00 810.00 * FED SS/Dis ER 113.63
* FED MedicareER 26.57
r OtherEarnings r Deductions
Code __ Hours __ Amounts Add to Gross 14 After-Tax 3.48
OTP 2.75 83.53 Y 12 Before-Tax 223.95
SDS 30.00 Y * 412 Nontaxable 223.95
OTP 4.25 {29.09 Y * 14 Nontaxable 3.48

ADP Enterprise HR screen print as of: 12/07/2021 01:51 PM