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2020 JM-1 28 FM Maricopa County Human Resources Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: January 28, 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 Debbie U. at ext. 66329 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 Signed: (4) NITI-A—RVAJBLICn (P.00.Xs2cyin My commission expires: OL-a-Q&J TIFFANY PARKERSON Notary Public- State of Arizona MARICOPA COUNTY My Commission Expires May 18, 2021 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: JA Duplicate or E Stale-Dated (definitions are on page 2) STATE OF ARIZONA OUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. /ulaimanL (i I LRCOLS (1), being first sworn, upon oath deposes and says: I 0% l9N.06tO (date)(2) a warrant/check was issued to the On or about above named perso /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 $ .(3) 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 ,9 8 day of -30.-v\i-kn 20 ab. (seal) 2.2(.,q(/ VI -2-2- AP yi Reas) n for original issue of Warrant/Check (8 Payroll El For Services or Goods furnished CI Treasurer's refund/payment Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) N.) AN 2 9 2020 oz. .7:70 LI Other: c) Revised April 2015 A.R.S. 11-632 & 11-644 Taxes Deductions Net Pay 515.79 322.33 1,823.48 Taxes ---- , FED SSDisMLvEE 165.11 FED MedicareEE 38.61 FED Withholdng 248.79 FED SS/Dis ER 165.11 FED MedicareER 38.61 Confirmed Check Amounts . Add to Gross HPA 266.16 Y Deductions 14 12 57 90ER * 91ER. 4.53 317.80 16.04 1.05 0.53 After-Tax Before-Tax Nontaxable Nontaxable Nontaxable -_Lucas April M MCl/EXM Paycheck View Name Lucas,April M Checkil,l Issue Date Earnings : 22696347 01/22/2020 2,661.60 Regular and Overtime Earnings Reg Hours Reg Pay OT Hours OT Pa 32.00 1064.64 40.00 1330.80 ADP Enterprise HR screen print as of: 01128/2020 12:28 PM