STAMPED & REDACTED DARRELL SCOTT.PDF

Maricopa County
Human Resources

Tiny DEA

Memo

To: Juanita Garza, Clerk of the Board

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From: Monica Reyes JM
Date: November 19, 2021 ish
Re: Replacement of Lost Payroll Warrants a

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.

Stale Dated Warrant (Over 1 Year) Duplicate Warrant |

Thank you.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: O Duplicate or LO 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.
Darrell Scott (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about _11/1 0/21 (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 $ 802.27 (3)

Signed: ord of oll ~ (4)

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_ 1A ___day of _ Nev 20. 2\

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
2 Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 584349 (seal)
Expires November ®, 2022

My commission expires:
W.Q.a7aa

Warrant/Check Number
(if known) (6) 2309 1 81 6

cromipacgane (11/40/2024

Reason for original issue of Warrant/Check (8):
fm Payroll
C1 For Services or Goods furnished
11/19/2021
O Treasurer's refund/payment

1 Other:

Revised April 2015

( Paycheck View

Name Scott,Darrell L Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23091816 11/10/2021 1,151.22 181.08 167.87 802.27
~ Regularand Overtime Earnings ——-_---—-—— - > Taxes -"
Reg Hours Reg Pay OT Hours OT Pay FED SSDisMLVEE M137
FED MedicareEE 16.69)
FED Withholdng 51.63
4.50 85.28 * FED SS/Dis ER 71.37
* FED MedicareER 16.69
r OtherEarnings ° — r Deductions
Code Hours _ Amounts Add to Gross 14 After-Tax 2.19
SFP 2.75 52.11 Y 101 Before-Tax 25.00
VFP 37.25 705.89 Y 12 Before-Tax 140.68
FLU 19.25 N * 42 Nontaxable 140.68
SFP 1.00 18.95 Y * 14 Nontaxable 2.19

ADP Enterprise HR screen print as of: 11/19/2021 11:18 AM