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Stale Dated Warrant (Over 1 Year) 2020 HAY 18 PM 1: 2* 1,14pA Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: May 1, 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 Monica at x 6-8051 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Thank you. (seal) EILEEN W1LLIAMS-PREAS Notary Mk - Stele dArtrona MARICOPA COUNTY Commission # 654349 Expires November 9,2022 My commission expires: Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Ig 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. Joshua B Martin Name/Claimant On or about 05/13/2020 (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 $ 1,305.13 .(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 I 6 day of frVA-1 20DO . MASZYY0— NOTARY PUBLIC (1), being first sworn, upon oath deposes and says: Warrant/Check Number (if known) (6) 23013039 Original Date of Issue (if known) (7) 05/13/2020 Reason for original issue of Warrant/Check (8): Payroll O For Services or Goods furnished O Treasurer's refund/payment O Other: Revised April 2015 A.R.S. 11-632 8t 11-644 811067429 - Martin,Joshua B Cl - Maricopa County 5114 - 4th Ave Jail NEX-Non Exempt Leave W/Py 05/12/2020 Reg/FT Regular and Overtime Earnings ------------------------ Reg Hours Reg Pay OT Hours OT Pay Company MCI Pay Group: NEX Period End 05/03/2020 Page 813 Line: 1 Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N 811067429 - Martin,Joshua B - MC1/NEX ( Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Martin,Joshua B Confirmed Check Checkt 23013039 Issue Date 05/13/2020 Earnings 1,906.38 Taxes 301.69 Deductions 299.56 Net Pay 1,305.13 Amounts Add to Gross OTP LWO VAC 0.25 7.25 8.50 221.60 9.78 - Taxes -- FED FED FED * FED * FED Deductions 82 91B 92 98B 100 SSDisM LvEE MedicareEE Withholdng SS/Dis ER MedicareER After-Tax After-Tax After-Tax After-Tax Before-Tax 14.24 4.81 7.01 1.00 50.00 ADP Enterprise HR screen print as of: 05/14/2020 04:48 PM