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Maricopa County Human Resources 2020 JAN -8 a: 17 02144 Memo To: Fran McCarroll, Clerk of the Board From: Debbie Upton Date: January 8, 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. 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 02/25/2015 (4) EILEEN WILL1AMS-PREAS Notary - Stata of Arizona MARICOPA COUNTY Commission 0 504349 Expiree November MA iisrollgoart.1441 NOTARY PUBLIC My commission expires: (seal) Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: ErlDuplicate or El Stale-Dated (definitions are on pa ge 2) STATE OF ARIZONA COUNTY OF MARICOPA Reler+ SaA Name raiment Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. (1), being first sworn, upon oath deposes and says: On or about I 2,I214 \ 20 1 (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/c issued kcis hini/heciin the sum of $ 1 ) 051a7V .(3) Signed: Note: Please attach a copy bf the warrant/check if available and/or any other evidence that a warranVcheck was originally issued. (5) Subscribed and sworn to before me this 1 day of JON\ 20 20. Warrant/Check Number (if known) (6) Original Date of Issue (if known) (7) -9-(2921.4913* a-I aq1Q00 r ROVED Reason for original issue of Warrant/Check (8): 'fyf Payroll 111 For Services or Goods furnished JAN 09 ?1)20 17 El Treasurer's refund/payment Cr') El Other: CAUsers\williamse\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\FITTDL74G\Warrants Checks notice of claim.doc Revised April 2015 A.R.S. 11-632 81.11-644 CO2 —0 aIin , Robert J MCI - Maricopa County 8052 - Court Security NEX- Non Exempt Active 10/21/2019 Reg/FT Company: MCI Pay Group: NEX Period End 12/15/2019 Page: 1341 Line: Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N Name Salin,Robert J Confirmed Check Checkt 22692608 Issue DatE 12/24/2019 Earnings 1,280.00 Taxes • 228.22 Deductions Net Pay 1,051.78 r Regular and Overtime Earnings Reg Hours Reg Pay OTHours OT Pa 640.00 640.00 Code Hours Amounts Add to Gross Taxes FED FED FED FED * FED Deductions 57 * 90ER 91ER 11 SSDisMLvEE MedicareEE Withholdng SS/Dis ER Medica reER Nontaxable Nontaxable Nontaxable Nontaxable 40.00 40.00 r Other Earnings 79.36 18.56 84.22 79.36 18.56 16.04 0.51 0.26 133.25 ADP Enterprise HR screen print as of: 01/07/2020 03:51 PM