STAMPED & REDACTED - FOR AGENDA ATTACHMENT - ERIK LONGENECKER.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

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From: Sonny Villacorta
Date: June 24, 2024

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 Sonny at ext. 63756 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

Zh pramuap PLOY

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

This application is for; 4 Duplicate or O Stale-Dated (definitions are on page 2}

STATE OF ARIZONA |
COUNTY OF MARICOPA

Erik Longenecker ing fret as and says:
a NaC eee LY, being first sworn, upan oath deposes and says:

On or about 8682824 6-2-PELe, 0.2) 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.

Instruction sheet which is page 2 of this form,

Note: Numbers on this form correspond to numbers on the |

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 ¢750 WS TT Lay

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

Signed; Erik Longenecker

(5) Stfpscribed and sworn to me this 19th ___day of Yune 2024

& a

TARY PUBLIC

LAURINDAR.
Notary Priblor Site ook

Manicopa coun =
Exgions Fobrumey 1.2027 (42!)

My commission expires:

Warrant/Check Number
(Gf known) (6) O24 | ol oS).

‘Original Date of Issue

{If kaown) (7) J le BLY -

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

O For Services or Goods furnished

{Treasurer's refund/payment
{] Other:

6/28/24

Revised Apri 2015

Maricopa County 301 W, Jefferson

Erik Longenecker
Name Company e ID} Pay Period Begin| Pay Period End| Check Date} Check Number]
Erik Longenecker (Maricopa County 05/13/2024) 05/26/2024) 06/05/2024,
t i Hours Worked} Gross Pay| Pre Tax Deductions: Employee Taxes] Post Tax Deductions} Nat Pay}
[Current 0,00} 750.00) 0.00} 91.23} 0.00 658.77}
YTD 0.00} 750.00) 0.00) 91.23 0.00} 658.77|
Earnings = b _ Employee Taxes _
[Description Dates Hours Rate Amount YTD Hours YTD Amount} |Description Amount YTO}
Intern Stipend 05/13/2024 - 05/26/2024 0 0 750.00 o 750.00} [OASDI 46.50 46.50)
Medicare 10.88 10.88)
Federal Wilhhalding 18.85 18,85)
State Tax - AZ 15.00 15.00)
Earnings 750.00 750.00] | Employee Taxes 91.23 91.23)
Taxable Wages
[Description Amount YTD}
IOASDI - Taxable Wages 750.00 750,00)
Medicare - Taxable Wages 750,00 750.00)
Federal Withholding - Taxable Wages 750.00 750.00}
State Tax Taxable Wages - AZ 750.00 750.00}
Federal} Li wu: State)
Marital Status Single or Married filing separately|
Allowances (] 0.00%,
Additional Withholding (i)
= Payment Information a = Te Pa SES
iBank Account Name Account Number USD Amount Amount
(Check) 658.77 __USD|