STAMPED & REDACTED DORA ERIKA CARRASCO RODRIGUEZ 10.13.21.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board
From: Daniel Villalba (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, Sui

Stale Dated Warrant uplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

AFFIDAVIT/NOTICE OF CLAIM j 10/27/2021

STATE OF ARIZONA

COUNTY OF MARICOPA

Dora Erika Gyrtsto Rodrigues BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:

That on the 3 le day of O Croley , 20 2\ , he/she presented

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

month of OCtoloey , said claim being in the sum of

One thosanek three hundved and forcy -fow dollars and Sixty Seven Cents
Dollars ($. (24 Fi : 6 T ) in payment of which the Board of Supervisors caused the

Warrant No. (0.2.3 0851854 to be issued on lo /\3 , 20 7a | , 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. OU 2368S 7S4 In the sum of $ (3 a4 it ~ *
Dated tHAFS~ IO/14_,20 2 \__ Signed: Clk, VA cb etepiey
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 _ 1] day of OCt ,20Z!

L2ALC HR

Notary Public

My commission expires: 2 / o4 ( 2OcSs BENJAMIN ANDRADE, JR.

Notaty Public - State of Arizona
MARIGOPA GOUNTY
Commission # 860060

Expires February 4, 2028

UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO:
Name: | Dori bx ike Cawosco Rody L4u’e Telephone Number: Ypo 296 4024
Address: 4424 € baseline ¥d Employee D4: O11 384 86
Adtieowe Fi parting ME #042.

01/31/2013

( Paycheck View

Name Rodriguez,Dora E Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23085759 10/13/2021 1,344.67 215.86 229.91 898.90
r Regularand Overtime Earnings Taxes
RegHours  RegPay  OTHours OT Pay FED SSDisMLVEE 80.08
FED MedicareEE 18.73
40.00 669.20 | FED Withholdng 69.70)
40.00 669.20 * FED SS/Dis ER 80.08)
* FED MedicareER 18.73
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 103 After-Tax 10.00
OTP 0.25 6.27 Y 14 After-Tax 2.56
44 Before-Tax 43.40
50 Before-Tax 0.66
61 Before-Tax 8.97

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