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• • ."1" a c ) C3 P 1 f.9 -73 e n Maricopa County Human Resources Memo C:11 To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: April 9, 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 Linda G. at ext. 63770 for any questions. Please route approved Affidavits back to County Payroll, Suite 220. Stale Dated Warrant Thank you. Replacement Lost Warrant Form Duplicate Warrant 1 7 96-D 02/25/2015 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 7 Duplicate or 0 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 Datle 2 of this form. Ramona C Lopez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 01-Apr-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 warravie k be issued to him/her in the sum of,$ 1 ,057-99 -(3) Signedr, (4) Note: Please attach a copy of thq)warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this CI day of Isvpri t 20 DD ;L._ jA5L) NOTARY RUKIC My commission expires: TIFFANY PARKERSON Notary Public. State of Arizona MARICOPA COUNTY My Commission Expires May 18, 2021 Warrant/Check Number if known) (6 23008103 01-Apr-2020 A trin-a . tiiili I_Nennt !I 2020 Payroll D For Services or Goods furnished MARICOPA COUNTY Eli Treasurer's refund/payment Eli Other: Reason for original issue of Warrant/Check (8): Name Lopez,Ramona C Checkii Issue Date 23008103 04/01/2020 Regular and Overtime Earnings ! Reg Hours Reg Pay OT Hours 40.00 640.00 40.00 640.00 Confirmed Earnings 1,412.00 OT Pay Taxes 183.02 , Taxes FED FED FED FED FED Check Deductions 170.99 SSDisMLvEE MedicareEE Withholdng SS/Dis ER MedicareER f Other Earnings Code Hours OTP OTP Add to Gross Deductions 14 12 * 57 * 90ER * 91ER After-Tax Before-Tax Nontaxable Nontaxable Nontaxable 2.40 168.59 16.04 0.51 0.26 Amounts 2.00 48.00 Y 3.50 84.00 Y Net Pay 1,057.99 87.55 20.48 52.61 87.55 20.48 r Paycheck View MCY- Earnings Taxes Deductions Garnishments Special Accumulators Distributions ADP Enterprise HR screen print as of: 04/09/2020 09:27 AM