STAMPED & REDACTED - FOR AGENDA ATTACHMENT - REYNA GONZALEZ.PDF

yn
on GLER} rs iso's
BOAO OE oR COUNTY. Naricona County
2024 MAY 16 PH 3:07 Human Resources
2

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: May 16, 2024

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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, 8" Floor.

Stale Dated Warrant Duplicate Warrant

Thank you.

MC30

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: Duplicate or C state-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.

Reyna Gonzalez
Name/Claimant

(1), being first sworn, upon oath deposes and says:

On or about 5/8/2024 (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 $957.25 (3)

(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 \G™ day of Moy 2024 .

veg

NOTARY PUBLIC

NATHALIE RIVAS
Notary Public - State of Arizona

My_cgmmission expires:
MARIGOPA COUNTY

4/7077 Gomtniesion # 645918 (seal)
U Expires Merch 4, 2027
Warrant/Check Number
(if known) (6) 52894276
Original Date of Issue
(if known) (7) 05/08/2024

Reason for original issue of Warrant/Check (8):
4 Payroll

OO For Services or Goods furnished

O Treasurer’s refund/payment
O Other:

5/17/24

Revised April 2015 ~

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003 _ +1 (602) 5063519
Reyna Gonzalez

Name |Company. yeas cee Employee ID] Pay Perlod Begin|___ Pay Period End] © Check Date|_ Check Number]

Reyna Gonzalez [Maricopa County 04/15/2024 04/28/2024 05/08/2024

pope eee - |= Hours Worked} Gross Pay| Pre Tax Deductions}. Emplayee Taxes} “Post Tax Deductions} —

|Current 64.00} 1,300.10} 187.83) 183.07) 1.95)

YTD 64.00} 4,300.10} 157.83} 183.07| 1.95

ace Fn ee | See ae : 3

‘Description Dates Hours Rate Amount YTD Hours YTD Amount} |Description Amount YTO

[Admin Leave With F04/22/2024 - 04/28/2024 2 19.15 38.30 2 38.30| [OASDI 80.61 80.61

Leave Without Pay 04/22/2024 - 04/28/2024 44.25 0 0.00 0.00} |Medicare 18.85 18.85}

JOIC Warrants SIMS04/17/2024 - 04/28/2024 20.25, 1 20,25 20.25 20.25] |Federal Withholding 60.76 60.76)

|Overtime Time One04/17/2024 - 04/21/2024 0.25 9.795 7.24 0.25 7.24} |State Tax - AZ 22.85 22.85)

Regular Pay 04/17/2024 - 04/28/2024 63.75 19.15 4,220.81 63.75 1,220.81

|Shift Differential Thi04/17/2024 - 04/28/2024 18 0.75 13.50 18 13.50

Earnings 1,300.10 1,300.10} | Employee Taxes 183.07 183.07

esis = Pre‘Tax Deductions] <0 Tene Post Tax Deductions =

[Description Amount YTD} |Description Amount YTD

IDB - ASRS 157.83 157.83} [ASRS LTD 1.95 1.95

Pre Tax Deductions 157.83 157.83] | Post Tax Deductions 1.95 1.95)

Bs 5 Employer Paid Benefits = E = 5S vTaxable Wages 2S

Description Amount YTD} |Description Amount YTD}

IASRS LTD 1,96 1.95] JOASDI - Taxable Wages 1,300.10 1,300.10)

IDB - ASRS. 157.83 157.83] |Medicare - Taxable Wages 1,300.10 1,300.10}

Federal Withholding - Taxable Wages. 1,142.27 1,142.27
Employer Paid Benefits 159.78 159,78] |State Tax Taxable Wages - AZ 1,142.27 1,142.27
Ee __ Federal} _ _Statej | Ss _ Absence Plans sere

Marital Status Single or Married filing Description Accrued Reduced Available}
separately Floating Personal Day 8 te) 8]

Allowances 9 1.50%} |Sick - County 2.56 ) 2.56

Additional Withholding () [Vacation - County 3.86 0 3.86)

aoe q Gene ene __Payment information S255 BE eS

iBank Account Name Account Number USD Amount Amount

(Check) 957.25 USD

Sov SCIASMIHCHES Gonaatez, Reyna 60576 05/08/2024 $987.25.

Check/VoucherNo, AOPCheckNumber Type Pages Wrap Print Sequence Delivery Method FS i
OQDOOROIEEIS 52894276 Check 1 000000001 7 Print & Online