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Maricopa County Human Resources Memo 23 To: Fran McCarroll, Clerk of the Board From: Zell Bullis Date: July 8, 2020 Re: Replacement of Lost Payroll Warrants A) Mtr 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 Nera 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. James Edward Davis (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) ad) EY (4) Note. lease attach a copy of the warrant/check if available and/or any other evidente that a warrant/check was originally issued. Signed: 7 ~ (5) Subscribed we, to before me this 4 day of Ju BAL 20.20, NOTARY PUBLIC ia LADEDDS Notary Public - Arizona My commission expires: camane Co. 1 #865489 own D, sda 13/2023 (seal) —— Warrant/Check Number (if known) (6) 0023007614 Original Date of Issue (if known) (7) 4/1/2020 Reason for original issue of Warrant/Check (8): Payroll [_]For Services or Goods furnished Treasurer's refund/payment _lother: Revised April 2015 A.R.S. 11-632 & 11-644 811124460 - Davis,James Edward _ 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, 601 : Adjustment: N Active 11/08/2016 Temp/PT | Line; 2 ( Paycheck View Name Davis,James Edward Confirmed Check Check# Issue Date ~ Earnings Taxes Deductions Net Pay 23007614 04/01/2020 60.00 60.00 r Regularand Overtime Earnings r Taxes RegHours —_ Reg Pay OT Hours OT Pay r OtherEarnings r Deductions Code _ Hours Amounts. _ Add to Gross| EPW 5.00 60.00 Y ADP Enterprise HR screen print as of: 07/07/2020 12:59 PM