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Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Zellnor Bullis Date: May 8, 2020 Re: Replacement of Lost Payroll Warrants R ECHVED p_5 MAY 1 1 2020 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS 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 Thank you. Replacement Lost Warrant Form 02/25/2015 NANCY LOVE Notary Public, State of Arizona Merloope County My Commission Expires January 31, 2022 (seal) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit! Claim Form This application is for: Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. Carole I Galvez (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 $ 217.10 .(3) Signed: /_-) (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 c:96 day of 'WI L 20,P 0. OAtt ./DA NOTARY PUBLI My com_narission expires: 3/ Jar) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): vl Payroll 0023007779 4/1/2020 For Services or Goods furnished OTreasurer's refund/payment 00ther: Revised April 2015 A.R.S. 11-632 & 11-644 Galvez,Carole I Company: MCI Off Cycle: N MC1 - Maricopa County Pay Group: NEX Separate Check # 0 2140 - Early Voting Services Period End 03/22/2020 Reprint N NEX- Non Exempt Page. 259 Adjustment: N Active 11/04/2014 Temp/PT Line: - Galvez,Carole 1 - MC1/NEX Paycheck View MCY-Eamings Taxes / Deductions Garnishments Special Accumulators Distributions Name Galvez,Carole I Confirmed Check Check t Issue Date Earnings Taxes Deductions Net Pay 23007779 04/01/2020 234.25 17.15 217.10 r.- Regular and Overtime Earnings I Reg Hours Reg Pay OT Hours OT Pay ' r r Taxes FED SSDisMLvEE 13.90 FED MedicareEE 3.25 * FED SS/Dis ER 13.90 FED MedicareER 3.25 [7.1. 4.00 52.00 13.25 172.25 T OtherEarnings I Code Hours Amounts Add to Gross Deductions 1 ERI 10.00 Y ADP Enterprise HR screen print as of: 05/0812020 11:39 AM