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Maricopa County
Human Resources
Vemo
RECEIVED % Deliveney
To: Fran McCarroll, Clerk of the Board MAY 20 2020
MARICOPA COUNTY
CLERK BOARD CF SUPERVISORS
From: Tiffany Parkerson
Date: May 20, 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 Tiffany at ext. 6-2406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Duplicate Warrant
Replacement Lost Warrant Form 1 02/25/2015
Stale Dated Warrant
Thank you.
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form COUN
This application is for: o pupticate 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.
Samuel Eyobli wl = (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 9/ 13/20 (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
ON to aad of ¢ 890.62 (3)
Signed: (4)
Note. Please attach a wy 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 __! q day of Mag { 20.90.
iron Porte rhovr
NOTARY PUBLIC)
. TIFFANY PARKERSON
My commission expires: e SY
S/\§1 202\ tey Commasion Exes (seal)
Warrant/Check Number
(if known) (6) 23013006
Original Date of Issue 5/13/2020
(if known) (7)
Reason for original issue of Warrant/Check (8):
@ Payroll
1 For Services or Goods furnished
O1 Treasurer's refund/payment
OO Other:
Revised April 2015 A.R.S, 11-632 & 11-644
8831 - Vector Lab Period End 05/03/2020
Active 04/20/2020. Reg/FT / Line 2
MCY-Earnings i
|811134939-Engbring SamuelW | Company: MC1 Off Cycle: N
MC1 - Maricopa County | PayGroup: NEX Separate Check # 0
Reprint: N
NEX-NonExempt Page: 1466 Adjustment: N
Name Engbring,Samuel W Confirmed Check
Check# Issue Date Earnings Taxes Deductions
23013006 05/13/2020 1,280.00 137.64 251.74
Net Pay
890.62
Earnings Type: Hours Earnings Dates Hourly Rate: 16.0000
Regular Hours: Begin: 04/20/2020 Additive Rate:
Overtime Hours End: 05/03/2020 Department 8831
RegEarnings: Wk# 00/ N JobCode: THC030
+_T Position Nbr 70453
Fixed Hours:
Work Order:
State/Locality: AZ /
/ TaxPeriods: 1 Biweekly
7 OtherEarnings
Account/Fund: 100D8808831VECT1000 P88041 TaxMethod: Annualized
Addl #: Addl Pay Reason:
ADP Enterprise HR screen print as of: 05/20/2020 07:18 AM