STAMPED & REDACTED JOSPEH SAKI.PDF

Maricopa County
Human Resources

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To: Cindy Goelz, Clerk of the Board =

From: Daniel Villalba (Payroll Specialist)
Date: October 11, 2021 on

Re: Replacement of Lost Payroll Warrants

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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.

Duplicate Warrant

Stale Dated Warrant

Thank you.

Replacement Lost Warrant Form 1

02/25/2015

10/15/2021

AFFIDAVIT/NOTICE OF CLAIM

STATE OF ARIZONA

COUNTY OF MARICOPA

Fosebh Selkh BEING FIRST DULY SWORN

OATH, DEPOSES AND SAYS:

That on the 6" day of Detbbey ,20_ZI_, he/she presented

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

month of Seftomber , said claim being in the sum of

One. Howsend dhnee lwindred and two with siehy-three cons
Dollars ($ 4L., 202+ 63 ) in payment of which the Board of Supervisors caused the
Warrant No. to be issued on Septembey is® ,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. In the sum of $ 1,202. 60
Dated: Q cholet \ar ,20_24 signed: Asef] Zuhb
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 (e** day of Otfeber , 20.2.

Derennn Kogan WManigoree
Notary Public

issi <pires: DIANNA LYNN MANZ
My commission expires: Notary Public herp dah
Commission # 800784

2, 2023 Expires March 7, 2023
UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO:
Name: VOEE Pu CAKL. Telephone Number:
Address: i oe Employee ID #:
Address:

01/31/2013

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( Paycheck View

Name Saki,Joseph A Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23080014 09/15/2021 1,793.24 307.03 183.58 4,302.63
Regular and Overtime Earnings
RegHours —_ Reg Pay OT Hours OT Pay SSDisMLVEE 107.34
MedicareEE 25.10
40.00 812.80 FED Withholdng 130.48)
25.00 508.00 * FED SS/Dis ER 107.34
* FED MedicareER 25.10
r Other Earnings r Deductions
Code _ Hours __Amounts Add to Gross 167 After-Tax 16.15
OTP 5.50 167.64 Y 379 After-Tax 7.97
VAC 15.00 304.80 Y 44 Before-Tax 69.48
50 Before-Tax 1.09
61 Before-Tax 21.35

ADP Enterprise HR screen print as of: 10/11/2021 09:47 AM

Management & Reversals —

Look up the details of a single payment or range of payments by using the form below. :
NOTE: The maximum check range is limited to 50 checks per request.

CHECK SEARCH _ DIRECT DEPOSIT SEARCH

STATUS: ALL v_

Saki Joseph A Ge # 23080014

$1,302.63 issued on 09/15/2021 Unpald/Uncashed