STAMPED & REDACTED KELSEY MANDERS.PDF

Maricopa County
Human Resources

Weng Detveeg Pia ~

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: December 14, 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

This application is for: JX Duplicate or LJ Stale-Dated (definitions are on page 2)
N
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.

K u a Mana OVS (1), being first sworn, upon oath deposes and says:
jame/Claima)
On or about 12.18 (2) (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 $ 1447 (Ae)

(3)
Signed: _ p4entes IF TAL (4) Rete lfolig
r any other

Note. Please athech a copy of the warrant/check if available and/o,
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this 4 day of Dee 20.2!

NOTARY PUBLIC

. . EILEEN WILLIAMS-PREAS
My commission expires: Notary Pub State of Aizona
W-O. 2022 Commission # S64940 (seal)
Expires November 9, 2022
EEE
Warrant/Check Number 23097876
(if known) (6)
Original Date of Issue 12/08/2021
(if known) (7)

Reasgn for original issue of Warrant/Check (8):

Payroll
. . 12/21/2021
O For Services or Goods furnished =
O Treasurer’s refund/payment
O Other:
Revised April 2015 A.R.S. 11-632 & 11-644

“Alen p

(F Paycheck View

Name Manders,Kelsey L Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23097876 12/08/2021 2,061.60 358.15 255.85 1,447.60
r Regularand Overtime Earnings Taxes
Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLVEE 127.82
FED MedicareEE 29.89
40.00 1030.80 FED Withholdng 151.58
24.00 618.48 * FED SS/Dis ER 127.82
“* FED MedicareER 29.89
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 14 After-Tax 3.92
HPA 16.00 412.32 Y 12 Before-Tax 251.93
* 42 Nontaxable 251.93
* 14 Nontaxable 3.92

ADP Enterprise HR screen print as of: 12/14/2021 01:22 PM