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Maricopa County Human Resources = To: Fran McCarroll, Clerk of the Board nas 2 ) From: Zellnor Bullis 8 Date: November 24, 2020 a Re: Replacement of Lost Payroll Warrants g 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 B. at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or L] 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. Sharon Rhone (1), being first sworn, upon oath deposes and says: Name/Claimant On or about October 28, 2020 (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 on in the sum of $538.50 (3) Signed: > AL... as = ——— (4) S Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) a) ay his_/O tay of Mnvourbe- 20 Ve. V wera. NOTARY PUBLIC - REBEKAH PARENT =. Notary Public - State of Arizona ED Meinieion #005824 My commission expires: Expires Mey 19, 2024 Nl g - Wt Y — (seal) Warrant/Check Number (if known) (6) 23030775 Original Date of Issue (if known) (7) 10/28/2020 Reason for original issue of Warrant/Check (8): Payroll L_IFor Services or Goods furnished DEC,O 3 2020 L_Itreasurer’s refund/payment other: Revised April 2015 A.R.S. 11-632 & 11-644 | eee MC1 - Maricopa County 2120 - Election Day Services ELE -Elections Active 10/05/2020 Temp/PT Company: MC1 Off Cycle: N Pay Group: ELE Separate Check # 0 Period End 10/18/2020 Reprint: N Page: 2290 Adjustment: N Line: 1 MC1/ELE — - Rhone,Sharon - (Paycheck View Name Rhone,Sharon Confirmed Check Check# Issue Date Earmings Taxes Deductions 23030772 10/28/2020 538.50 - Regularand Overtime Earnings [al | Taxes RegHours RegPay OTHours OT Pay — r OtherEarnings r Deductions Code _ Hours Amounts Add to Gross EOW 3.25 58.50 Y EPW 40.00 480.00 Y ADP Enterprise HR screen print as of: 11/24/2020 08:35 AM