STAMPED & REDACTED DULCE CARRIZOZA VALENZUELA.PDF

Maricopa County
Human Resources

Niemo DEC 06 2021
. MARICOPA, COUNTY
CLERK BOARD OF SUPERVISORS

To: Cindy Goelz, Clerk of the Board

From: Zell Bullis
Date: December 6, 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 Zell Bullis at ext. 60409 for any questions. Please
route approved Affidavits back to County Payroll, Suite 400.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 04/08/2021

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.
Dulce Carrizoza Valenzuela (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 11/24/21 (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 ¢ 909. 96 (3)

Signed: ( abe Bigg. (4)

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

(5) th and sworn fo before me this Bhd day of Teeemboe. 20 2/

NOTARY ut) C/ “DENISE MAUPIN |

itotary Public - State of Anzona

MARICOPA COUNTY
My commission “ome Gormmission #600813
A | Q Jaos's EOE ousal (seal)
Warrant/Check Number
Cif known) (6) 0023094761
Original Date of Issue
(if known) (7) 11/24/21
Reason for original issue of Warrant/Check (8):
Payroll
O For Services or Goods furnished
O) Treasurer's refund/payment 12/07/2021

O Other: ~

Revised April 2015

| a - Carrizoza Valenzuela,Dulce M Company: MC1 Off Cycle: N
MC1 - Maricopa County _ PayGroup: NEX Separate Check # 0
1603 - Financial Svcs and Quality Ctl _ Period End 11/14/2021 Reprint: N
NEX-Non Exempt / Page 81 Adjustment: N
Active 05/04/2020 Reg/FT | Line: 1

- Carrizoza Valenzuela,Dulce M - MC1/NEX

( Paycheck View (mM ns | G
Name Carrizoza Valenzuela,Dulce M Confirmed ‘Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23094761 11/24/2021 1,339.20 109.18 320.06 909.96
- Regularand Overtime Earnings [al Taxes ia
RegHours RegPay  OTHours OT Pay = FED SSDisMLVEE 13.57)
FED MedicareEE 17.20)
32.00 535.68 FED MedicareER 17.20)
AZ Withholdng 18.41 |
- OtherEarnings | | Deductions a
Code __ Hours Amounts Add to Gross } 98A After-Tax 0.23 | eS
HOL 8.00 133.92 Y 98B After-Tax 1.00
14 After-Tax 2.54
44 Before-Tax 123.78
x 50 Before-Tax 1.45 | jel

ADP Enterprise HR screen print as of: 12/06/2021 10:38 AM

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