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Maricopa County Human Resources Memo To: Fran 'McCarroll, Clerk of the Board From: Zellr or Bullis Date: Aloft 24, 2020 Re: Rep 3cement of Lost Payroll Warrants -i -RECERIED - H.%,01-ztx-oto osv APR 2 4 2020 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Please find af ached 1 Affidavit/Notice of Claim(s) for lost payroll warrar for inclusion on the next available Board agenda. The attachedlem(s) have been researched to ensure that the warrant(s) in ( ,bestion have not been cashed or previously re- issued. The warrant(s) have had a stop payment done. Please call ZOnor B. at ext. 60409 for any questions. Please route approvui Affidavits back to County Payroll, Suite 220. Stale Dated 1) arrant Thank you. Replacement UN Warrant Form 1 02/25/2015 PR 2,4 2020 (1,0f/goet9 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or LI 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. Milton Michel Masson (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 warr_rtich k be issu Signed: mffie4i in the sum of $ 73750 .J__. a-1--26------- , (4) 43) 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 1 7 day of iipf- F 207(). Jameson Caltablano Notary Public Marlcopa County, Arizona My Comm. Expires 08-06-2022 Commission No. 553268 NOTARY PUBLIC My commission expires: Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) (seal) 00129368 4/1/2020 Reason for original issue of Warrant/Check (8): 0 For Services or Goods furnished 0Treasurer's refund/payment fl Other: Payroll Revised April 2015 A.R.S. 11-632 & 11-644 Issue Da F: 04/01/202 1 Check# 23008145 Earnings 737.50 Regular and Overtime Earnift s Reg Hours Reg Pay OT Hours OT Pay Net Pay 737.50 Deductions Taxes Taxes -Mas on,Milton Michel MCI - Maricopa C Dunty 2120 - Election C iy Services ELE- Elections Active 081 !8/2018 Temp/PT Company: MC1 Pay Group: ELE Period End 03/22/2020 Page: 1598 Line: 5 Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N 111111111111- Masson Milton Michel - MC1/ELE ( Paycheck View MCY-Earn gs j Taxes Deductions Garnishments Special Accumulators Distributions Name Masson,Milton Michl Confirmed Check - OtherEarnings Code Hours Deductions Amounts Add to Grosl EPS 59.00 737.50 ADP Enterprise HR screen print as of: 04/23/2020 11:52 AM