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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board sS From: Debbie Upton an om Date: July 6, 2020 Re: Replacement of Lost Payroll Warrants Please find attached _1 __ Affidavit/Notice of Claim(s) for lost Se 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 Debbie U. at ext. 66329 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: A Duplicate or CO state-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. Cousinio hue OM (1), being first sworn, upon oath deposes and says: On or about une AA 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 Signed: _ pl AA Note. Ple. ase 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 __a__day of _JW WA 20a». Gn Ww ee NOTARY PUBLIC My commission expires: WG. 2O3D—- Warrant/Check Number ’ (if known) (6) 230 ) G 0 0) ’ Original Date of Issue —— (if known) (7) W124 \2020 APPROVE Reason for original issue of Warrant/Check (8): JUL 07 2020 Z Payroll O Other: ly ee Revised April 2015 A.R.S. 11-632 & 11-644 Company: MC‘ Pay Group: NEX - Hudson, Caytlynn E MC1 - Maricopa County 5135 - Central Services-Food Services Period End 06/14/2020 NEX-NonExempt i Page: 994 Leave W/Py. 06/09/2020 Reg/FT | Line: 7 Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N ( Paycheck View Name Hudson,Caytlynn E Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23016603 06/24/2020 636.00 53.13 77.02 505.85 - Regularand Overtime Earnings : er fF Taxes RegHours RegPay OTHours OT Pay = FED SSDisMLVEE 39.43 FED MedicareEE 9.22 * FED SS/Dis ER 39.43 * FED MedicareER 9.22 AZ Withholdng 4.48 r OtherEarnings r Deductions Code Hours Amounts Add to Gross 14 After-Tax 1.08 AWP. 40.00 636.00 Y 12 Before-Tax 75.94 Hed 2 Nontaxable 75.94 * 14 Nontaxable 4.08 ADP Enterprise HR screen print as of: 07/02/2020 12:55 PM