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eee § Maricopa County HARICOPA COUNTY Human Resources 902) AUG -6 PM 4:5! Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: August 5, 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 Zellnor 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. Juan Jose Rodriguez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about April 1, 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 him/her in the sum of $69.00 (3) Signed) — les, 7-6 2o¢)(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) Subscribed and sworn to before me this / zat day of url y 2020. NOTARY PUBLIC JOSEPH EDHUINE Notary Public - Arizona Maricopa Co. / #578958 Expires 03/16/2024 My commissign expires: S/S VoVry (seal) L Warrant/Check Number (if known) (6) 23008428 Original Date of Issue (if. known) (7) 4/1/2020 Reason for original issue of Warrant/Check (8): APPR Payroll DATE (_]For Services or Goods furnished L_Itreasurer’s refund/payment L_lother: Revised April 2015 A.R.S. 11-632 & 11-644 -Rodriguez,Juan Jose » Company: MC1 Off Cycle: N MC1 -Maricopa County Pay Group: ELE Separate Check # 0 2120 - Election Day Services Period End 03/22/2020 Reprint: N ELE-Elections Page: 2134 Adjustment: N Active 11/04/2008 Temp/PT Line: 6 Paycheck View Name Rodriguez,Juan Jose : Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23008428 04/01/2020 60.00 : 60.00 r Regularand Overtime Earnings r Taxes Reg Hours Reg Pay OTHours —_ OT Pay r OtherEarnings ; Deductions Code Hours Amounts Add to Gross EPW 5.00 60.00 Y ADP Enterprise HR screen print as of: 07/31/2020 08:20 AM