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Maricopa County Human Resources Memo EC tk`. ,1/4.1tk To: Fran McCarroll, Clerk of the Board From: Tiffany Parkerson Date: May 5, 2020 Re: Replacement of Lost Payroll Warrants MAY 0 6 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 Tiffany at ext. 6-2406 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 tA(//t_ Ce-A/t/a NOTARY PUBLIC My commission expires: (seal) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: gi Duplicate or 0 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. SalViVab (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 0292-0:i° (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 $ U 1+0 .9, (e) .(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. 20 al (5) Subscribed and sworn to before me this day of i\-it Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) _ o4 I2/ioio Reason for original issue of Warrant/Check (8): "Payroll For Services or Goods furnished LI Treasurer's refund/payment El Other: n • i` S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644 - Khan,Savannah R MCI - Maricopa County 6934- Floodplain Permits EXM - Exempt EEs Active 04/06/2020 Reg/FT Company: MCI Pay Group: EXM Period End 04/19/2020 Page 632 Line: Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N - Khan,Savannah R MC1/EXM Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Khan,Savannah R Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 23011782 04/29/2020 2,241.11 346.31 253.82 1,640.98 E Regular and Overtime Earnings . 1 Reg Hours Reg Pay OT Hours OT Pay 44.00 1152.80 36.00 943.20 Taxes FED FED FED FED FED SSDisMLvEE MedicareEE Withholdng SS/Dis ER MedicareER 129.95 30.39 91.84 129.95 30.39 OtherEarnings Deductions Code Hours Amounts Add to Gross 14 12 12 * 14 After-Tax Before-Tax Nontaxable Nontaxable 3.56 250.26 250.26 3.56 UNI 145.11 ADP Enterprise HR screen print as of: 0510512020 08:23 AM