STAMPED & REDACTED DORA ERIKA CARRASCO RODRIGUEZ 9.29.21.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board
From: Daniel Villaloa (Payroll Specialist)
Date: October 25, 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 Daniel. at ext. 62406 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

10/27/2021
AFFIDAVIT/NOTICE OF CLAIM -

STATE OF ARIZONA

COUNTY OF MARICOPA

Dore Eriko larasto Rodrig U2. BEING FIRST DULY SWORN

OATH, DEPOSES AND SAYS:

ah
That on the 2 q day of S eptem ber , 20 2\ _, he/she presented

to Maricopa County, for payment a claim for services rendered or supplies furnished during the

month of Seiolem ev , said claim being in the sum of

Sithentved sixty-nine dollavs and jwenty Covs

Dollars ($ @ 649.20 ) in payment of which the Board of Supervisors caused the
Warrant No. 2. 3682 3 1 8 to be issued on__A L 24 ,20 21 , drawn on the

Payroll Clearing Account fund.

Affiant further says that although he/she was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost. Under penalty of
perjury, affiant hereby affirms that this claim is correct and the amount shown is due and owing.

WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said

Warrant No. 2308289 8 In the sum of $ 66 q 20 .
Dated: AA faa , 20 1\ Signed: Ly hadley

Affiant
*** A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the
replacement check.***

Subscribed and sworn to before me this_(4 day of O «+ 5,202

Notary Public

My commission expires:

celo4 (202.3
UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO:

BENJAMIN ANDRADE, JR.
Notaty Public - State of Arizona
MARICOPA COUNTY
Commission # 559050
Expires February 4, 2023

Name: ))O(6 Erika Cayrasco Rodriquer Telephone Number: 4902.46 1024
Address: yy 24 & Baseline. my Employee ID #: 8 \W\3 8 4 86
Address: Anasrmne ax ee LOHR

01/31/2013

( Paycheck View

Confirmed Check

Name Rodriguez,Dora E
Check# Issue Date Earnings Taxes Deductions Net Pay |
23082898 09/29/2021 669.20 86.33 83.05 499.82 |
r Regular and Overtime Earnings - Taxes z
RegHours —_ Reg Pay OT Hours OT Pay FED SSDisMLVEE 41.49
FED MedicareEE 9.70)
40.00 669.20 FED Withholdng 10.47
* FED SS/Dis ER 41.49
* FED MedicareER 9.70)
~ OtherEarnings r Deductions
Code Hours Amounts Add to Gross} | 14 After-Tax 1.27
12 Before-Tax 81.78
* 412 Nontaxable 81.78
* 14 Nontaxable 1.27

ADP Enterprise HR screen print as of: 10/25/2021 02:58 PM