STAMPED & REDACTED JOSELIUS ARBALLO.PDF

Maricopa County
Human Resources

Memo

To: Cindy Goelz, Clerk of the Board

From: Zell Bullis
Date: September 27, 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 Quiles Warrant ?

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: Duplicate or C] 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.
JOSELUIS ARBALLO (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about _ SEPTEMBER 15,2021 (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 $927-87 (3)
Signed: VPn— Gren (4)

Note. Please attach a copy of the warrant/check if available and/or any other

evidence that a warrant/check was originally issued,

orn to before me this GL. day of d AL. 20H.

HOPE M. OL
tary Public - State re

My,commission expires: No UIN
zona
LSE MY Commission Expires Apr 4

MARICOPA COUNTY (seal)
Warrant/Check Number
(if known) (6) 23079913

Original Date of Issue
(if known) (7) 09/15/2021

Reason for original issue of Warrant/Check (8):
[Vv] Payroll

[For Services or Goods furnished 09/28/2021

[treasurer's refund/payment

other:

Revised April 2015 A.R.S. 11-632 & 11-644

- Arballo, Joseluis G
MC1 - Maricopa County
2180 - Logistics and Warehouse Mngmt
NEX-NonExempt
Active 08/23/2021 Reg/FT

Company: MC‘
Pay Group: NEX

Period End 09/05/2021

Page. 265
Line: . 2

Off Cycle: N
Separate Check # 0
Reprint: N
Adjustment: N

Paycheck View

Name Arballo, Joseluis G Confirmed Check
Check# Issue Date Earnings Taxes Deductions
23079913 09/15/2021 1,346.40 263.80
- Regular and Overtime Earnings -
Reg Hours Reg Pay OT Hours OT Pay SSDisMLVEE
MedicareEE
40.00 673.20 Withholdng
40.00 673.20 SS/Dis ER
* FED _ MedicareER
r OtherEarnings r Deductions
Code _ Hours Amounts Add to Gross| 301 After-Tax
81 After-Tax
91B After-Tax
92 After-Tax
98B After-Tax

ADP Enterprise HR screen print as of: 09/27/2021 09:55 AM