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Maricopa County
Human Resources
Viemo
es
+ $80
To: = Fran McCarroll, Clerk of the Board % 2s
From: Linda Greinke S a
Date: October 2, 2020 we
Ns
Re: Replacement of Lost Payroll Warrants litead
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 Linda G. at ext. 63770 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you. : Aoger 2ASO
reQical Eyoarmna—
1
Replacement Lost Warrant Form 02/25/2015
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
?
This application is for: xf Duplicate or C1 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.
alex \¢ { WMetoy Gq (1), being first sworn, upon oath deposes and says:
ame/Claimant
On or about on/ Ue { 2072.0 (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 $ q \gt. (g0 (3)
Signed: \| Queue (4)
Note. Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
| ubscribed an to before mefthis__| day of CES 20 LO) |
NOTARY PUBLIC
STARR CLARK
Notary Public - Arizona
Pinal County
Commission # 571150
Expires September 03, 21
My commission expires:
OG-©3-Z3
My Commission
Warrant/Check Number
(if known) (6)
Original Date of Issue
9 (if known) (7) q / iV [ 2020
Ree br original issue of Warrant/Check (8):
AO Payroll
RE te
O For Services or Goods furnished
ERK. BOARD OF SUPERVISORS
MARS OPA SOUT
O Treasurer's refund/payment
O Other:
Revised April 2015 A.R.S, 11-632 & 11-644
a Amezcua,Valerie - MC1/NEX
Paycheck View |
Name Amezcua, Valerie Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23026250 09/16/2020 4,216.88 249.28 967.60
r Regularand Overtime Earnings r Taxes
RegHours — Reg Pay OTHours —_ OT Pay FED SSDisMLVEE
FED MedicareEE
40.00 600.00 FED Withholdng
40.00 600.00 * FED SS/Dis ER
* FED MedicareER
r OtherEarnings ) 7 Deductions
Code Hours __ Amounts Add to Gross ;
OTP 0.25 5.63 Y
OTP 0.50 11.25 Y
ADP Enterprise HR screen print as of: 10/02/2020 09:44 AM