STAMPED & REDACTED CANDIS MCGOVERN.PDF
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Maricopa County Human Resources Memo To: Cindy Goelz, Clerk of the Board From: Zell Bullis Date: October 28, 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 Zell Bullis at ext. 60409 for any questions. Please route approved Affidavits back to County Payroll, Suite 400. Stale Dated Warrant Duplicate Warrant Brll HY 82 190 128 Thank you. Replacement Lost Warrant Form 1 04/08/2021 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 1 puplicate or CJ 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. Candis MGovernt (1), being first sworn, upon oath deposes and says: Name/Claimant On or about _Cckober 13 -228\_ (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 $__! AOG6.OS (3) Signed: a AK (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 Z1__ day of Oc# 20_24. NOTARY PUBLIC EILEEN WILLIAMS-PREAS Notary Public - State of Arizona My commission expires: ] |-9- 2022 ommin $240, (seal) Warrant/Check Number 23085726 (if known) (6) Original Date of Issue (if known) (7) 10/13/2021 Reason for original issue of Warrant/Check (8): Ws Payroll C1 For Services or Goods furnished 10/29/2021 O Treasurer’s refund/payment . 1 Other: Revised April 2015 ARS. 11-632 & 11-644 - McGovern,Candis A MC1 - Maricopa County 3750 - Teaching and Learning EXM-ExemptEEs Active 09/20/2021 Reg/FT Company: MC1 Pay Group: EXM Period End 10/03/2021 Page: 322 Line: 3 Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N ( Paycheck View Name McGovern,Candis A Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23085726 10/13/2021 2,884.00 514.28 403.63 1,966.09 | - Regularand Overtime Earnings | 7 Taxes RegHours RegPay OTHours —_OT Pay FED SSDIsMLVEE 176.04 FED MedicareEE 41.17 40.00 1449.00 ! FED Withholding 277.18 ioe 144060 * FED SSiDis ER 176.04 * FED —_MedicareER 41.17 r OtherEarnings | 7 Deductions Code _ Hours Amounts Add to Gross 14 After-Tax 5.48 44 Before-Tax 34.51 63 Before-Tax 11.21 12 Before-Tax 352.43 * A1ER Nontaxable 358.72 ADP Enterprise HR screen print as of: 10/27/2021 12:42 PM