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Stale Dated Warrant (Over 1 Year) Maricopa County Human Resources 2020 tiAR 24 PH 2: 2r (Y1,3 Memo To: Fran McCarroll, Clerk of the Board From: Monica Reyes Date: March 24, 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. Signed: (4) 7-) NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Public - Stabs of Aii20118 MARICOPA COUNTY Commission 0 554349 Expires November 9, 2022 My commission expires: t woo- (seal) Warrant/Check Number (if known) (6) Original Date of Issue if known) (7 128755 3/18/2020 Appfication for a DupHcate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0/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 page 2 of this form. Greg A Ratcliff Name/Claimant On or about 3/18/2020 (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 $ 476.12 .(3) (1), being first sworn, upon oath deposes and says: 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 f2L1 day of inoLicc-f 20 20. Guttkdirrvi- IVY MARICOPA COUNTY 0 For Services or Goods furnished Reason for original issue of Warrant/Check (8): II Payroll 0 Treasurer's refund/payment 0 Other: Revised April 2015 A.R.S. 11-632 & 11-644 Name Ratcliff,Greg A Confirmed Check SSDisMLvEE MedicareEE Withholdng SS/Dis ER MedicareER 640.00 After-Tax Before-Tax Nontaxable Nontaxable Amounts - Ratcliff,Greg A MCI- Maricopa County 8052 - Court Security NEX- Non Exempt Active 03/02/2020 Reg/FT - Ratcliff,Greg A - MCVNEX Company: MCI Pay Group: NEX Period End 03/08/2020 Page. 1365 Line: Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N ( Paycheck View MCY-Earnings Taxes / Deductions Garnishments Special Accumulators Distributions ADP Enterprise HR screen print as of: 03/24/2020 08:39 AM