STAMPED & REDACTED ANDREW D. AGUERO.PDF
Extracted text (via ocr_local)
2967 characters
Maricopa County Human Resources 2021 0CT 26 PR 2:97 Memo To: Juanita Garza, Clerk of the Board From: Monica Reyes Date: October 26, 2021 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. 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: fl Duplicate or [1 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. Andrew D Aguero (1), being first sworn, upon oath deposes and says: Name/Claimant On or about October 13, 2021 (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 $976.58 (3) Signed: _< can tor (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 sworn to before me this 2 _L- day of Ock 202| . . ; = x DENISE GOSS Notary Public - Arizona Maricopa County Commission # 582456 sie” ~My Comm. Expires Jun 5, 2024 My commission expires: —+ n L (seal) Warrant/Check Number 153985616 — (if known) (6) iginal f I Original pate on [10/13/2021 Reason for original issue of Warrant/Check (8): fi Payroll 1 For Services or Goods furnished O Treasurer’s refund/payment as 10/26/2021 O Other: : Revised April 2015 ( Paycheck View Name Aguero,Andrew D Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23085616 10/13/2021 768.00 96.11 95.31 576.58 ~ Regular and Overtime Earnings - Taxes RegHours —_ Reg Pay OT Hours OT Pay FED SSDisMLVEE 47.62 FED MedicareEE 11.14 24.00 576.00 FED Withholdng 19.15 * FED SS/Dis ER 47.62 * FED MedicareER 11.14 r OtherEarnings r Deductions Code _ Hours Amounts Add to Gross} 14 After-Tax 1.46 FLT 8.00 192.00 Y 12 Before-Tax 93.85 LWO 8.00 N * 57 Nontaxable 16.04 * 90ER Nontaxable 0.75 * O1ER Nontaxable 0.38 ADP Enterprise HR screen print as of: 10/26/2021 01:57 PM Lost Ohtde.