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CLEKk FSUP HARIGO -PA Maricopa County Human Resources 2020 JAN 27 P?i 2: 02 Memo To: Fran McCarroll, Clerk of the Board From: Linda Greinke Date: January 27, 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 Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 02/25/2015 Signed: (4) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: pi 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. ct- gra/claimant ----txect( 03 (1), being first sworn, upon oath deposes and says: On or about 2-0?-0 date,) (2) a warrant/check was issued to the above named pe on/ent ty 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 $ L'D . .(3) Note: Please attach a co# 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 77411 day of \) QtAtetftt 20 otty P M commission expires: -At/1-1- ?-0PI3 LA TOYA KNIGHT Notary Public, State of Arizona Maricopa County Commission # 569036 My Commission Expires August 15, 2023 seal) Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) 00 ?-?-1,6°I 63713) opD/70 2-0 JAN I LULU Reason for original issue of Warrant/Check (8): )Sr Payroll El For Services or Goods furnished 0 Treasurer's refund/payment El Other: Revised April 2015 A.R.S. 11-632 & 11-644 811133988 - Gonzales,Cecelia M - MC1/EXM r Paycheck View MCY-Earnings Taxes Deductions Garnishments Special Accumulators Distributions Name Gonzales,Cecelia M Confirmed Check Checkt Issue Date Earnings Taxes Deductions Net Pay 22696338 01/22/2020 988.00 115.18 119.65 753.17 r Regular and Overtime Earnings Reg Hours Reg Pay OT Hours OT Pay 38.00 988.00 Taxes FED FED FED * FED * FED SSDisMLvEE 61.26 MedicareEE 14.33 Withholdng 23.93 SS/Dis ER 61.26 MedicareER 14.33 Deductions 14 12 * 12 * 14 Amounts Add to Gross After-Tax Before-Tax Nontaxable Nontaxable 1.68 117.97 117.97 1.68 ADP Enterprise HR screen print as of: 0112712020 12:09 PM