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Maricopa County Human Resources Memo To: From: Date: Re: Fran McCarroll, Clerk of the Board Tiffany Parkerson June 18, 2020 52:6 WY 61 NAP O28 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 Tiffany at ext. 6-2406 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 lane ‘ } Vd82 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. Vaughn, Bryant D (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 06/10/2020 (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 $1 1375.23 (3) Signed: (), Albin (4) i) md v U7 = 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 IS day of « \owe 20_20. NN wi AQVIL} Ponke AAQV) NOTARY PUBLIC ‘ TIFFANY PARKERSON fs \ Notary Public - State of Arizona My commission expires: (eae taal Ya Af (8, ACS May 18, 2024 (seal) Warrant/Check Number Original Date of Issue Date of Issue [96/40/2020 aa Reason for original issue of Warrant/Check (8): 7 / / 2220 fm Payroll FRAN McCARROLL C For Services or Goods furnished O Treasurer’s refund/payment O Other: Revised April 2015 A.R.S, 11-632 & 11-644 BE «Vaughn, Bryant D _. Company: MC1 Off Cycle: N MC1 - Maricopa County / Pay Group: NEX Separate Check # 0 6438 - Pavement Markings _ Period End 05/31/2020 Reprint: N NEX-NonExempt Page: 1142 Adjustment: N Active 04/27/2020 Reg/FT | line 5 Name. Vaughn,Bryant D Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23015373 06/10/2020 1,900.01 294.69 230.09 1,375.23 r Regularand Overtime Earnings rT lees [al RegHours RegPay OTHours — OTPay — ED SSDisMLVEE 117.80) FED MedicareEE 27.55) 40.00 950.00 FED Withholdng 135.95 29.50 700.63 * FED SS/Dis ER 117.80 a * FED MedicareER 27,55) r OtherEarnings = r Deductions Code Hours Amounts. Add to Gross; }-— 14 After-Tax 3.23 HOL 8.00 190.00 Y : 12 Before-Tax 226.86 VAC 2.50 59.38 Y o * 185ER Nontaxable 167.00 st 42 Nontaxable 226.86 * 14 Nontaxable 3.23 ADP Enterprise HR screen print as of: 06/17/2020 03:34 PM