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Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
662% Wd 92 SAY 8282
From: Linda Greinke Jy
Date: August 26, 2020
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 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.
Replacement Lost Warrant Form 1 02/25/2015
RICE
Soe,
vee
Application for a Duplicate or Stale-Dated Warrant/Check aa
Affidavit/ Claim Form
This application is for: a Duplicate or CO 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.
Shadrick ick ~ lone (1), being first sworn, upon oath deposes and says:
“Namie/Claimant
On or about é / S 51. WD (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
eet Ah lbibe to himfher in the sum of $ 57 A AD (3)
(4)
Note. Please attacH a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Signed:
(5) Bubssaibed and sworn to before me this 2b day of we 20.20.
Wows.
NOTARY PUBLIC
My commission expires:
li .203ae,
(seal)
Warrant/Check Number ;
(if known) (6) ar DB a aN a7?
Original Date of Issue , -
(if known) (7) dos | 2030
Reason for original issue of Warrant/Check (8): 2 6 2020
ayroll
O For Services or Goods furnished
OO Treasurer's refund/payment
O Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644
GE Jones, Shadrick - MC1/NEX
( Paycheck View | MCY-Eamings | Taxes |{ Deductions [ Gamishments [ Special Accumulators [ Distributions
Name Jones, Shadrick Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23020927 08/05/2020 779.20 105.13 95.22 578.85 v4
r Regular and Overtime Earnings 7 7 Taxes
RegHours RegPay § OTHours OT Pay - FED SSDisMLVEE 48.31
FED MedicareEE 11.30
FED Withholdng 20.85)
38.00 740.24 * FED SS/Dis ER 48.31
2.00 38.96 * FED MedicareER 11.30)
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross| 14 After-Tax 1.40
12 Before-Tax 93.82
* 12 Nontaxable 93.82
* 14 Nontaxable 1.40
ADP Enterprise HR screen print as of: 08/26/2020 12:32 PM