STAMPED & REDACTED - FOR AGENDA ATTACHMENT - EDGAR CAMPOS AGUILAR.PDF

Maricopa County
Human Resources

yand delivered.

RECEIVED ,,.

MARICOPA COUNTY
. CLERK BOARD OF SUPERVISORS
To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: May 8, 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.

Replacement Lost Warrant Form 1 02/25/2015

ication for a Dupt

Appl icate of Stale-Dated Warrant/Check

apfidavit/ Claim Form

This application is for: ‘- Duplicate or Ww] State-Dated (definitions are oF page 2)

STATE O ho
STALE f - . 6
COUNTY ¢ ARIZONA Note: Numbers on this form correspond to nurnbers on the

. OF MARICOPA Instruction sheet which is page 2 of this form.

Uber, Cav pa and says:

j

| NanBICaIAT CAAA Ie ¢ 1), being first sworn, upon oath deposes

On or about __ _jo/ 25/12 (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 1
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

Ti £0 (3)

warrant/check be issued ta him/her in the sum of $ :

Signed: Lie (4)

Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally Issued.

2024.

P)
(5) Subsefibed and sworn to before me this 2°" __day of May

ag

SNGTARY PuBLte— —s

My commission expires:
10 “20-26

Warrant/Check Number A
(known) (6) M/ fi 52755693

Original Date of Issue 7
_ (if known) (7) . | 0 / 26/23 .

Reasgn for original issue of Warrant/Check (8):
@ Payroll

Cl For Services or Goods furnished____

(0 Treasurer’s refund/payment

(7 Other:

5/29/24

Revised April 2015

Maricopa County 301 W. Jsiferson St.
Edgar Campos Aguilar

hack Datel « Check Number:

{Company [Pay Panod En]
Maricopa County 10/02/2023) 10/15/2023} 10/25/2023}
ss] Post Tax Deductions| «
0,00) 1,682.50) 0.00)
4,536.20 44,526.79 254,70)

Amount YTD Hours YTD Amount] |Description Amount YTO
Critical Staffing Diffe 0 2145.76 2,748.65} [OASOI 310.00 4,880.79
Excess Life Insuran 0 i] 3.19} [Medicare 72.50 1,144.47)
Fioating Personal OD Lt) 8 201.84] |Federal Withholding 1,160.00 7,285.90
Holiday 0 56 1,422.88] [State Tax - AZ 100,00 1,218.63}
Muittilingual Differen Q 4719.5 859.74
Overtime Time One Qo 426.25 17,607,42!
Regular Pay 0 1195 44,070.45)
Sheriffs Office Rete 10/09/2023 - 10/15/2023 0 oO 5,000.00 0 10,000.00;
Shift Differential Thr QO 859.5, 644.54
‘Shift Differential Tw. i) 1274 636.95)
Sick Leave 0 47.5 $54,02|
Uniform Allowance * 0 ti) 800.00)
[Vacation CY) 8.75 220.76
Earnings 8,000.00 79,670.41] | Employee Taxes 1,582.50 14,526.79

YTD)

Description Amount YFD] Description Amount

IOC - CORP 3,588.18} [Addl Life - Securian 19.20
IEE DHMO-Cigna Dentai Care 118.14] |CORP Tier 3 DC LTD 227.44
IEE UHC HDHP with HSA 807.66} [Child Life - Securian 5.06)
IEE Vision 22.22)

Pre Tax Deductions 0.00 4,536.20] | Post Tax Deductions 0.00 251.70:

\Description Amount YTD} [Description Amount YTD|
Basic AD&D - Securian ER 8.28] [OASDE - Taxable Wages 5,000.00 78,722.39
Basic Life - Securian ER 16.41] |Medicare - Taxable Wages 5,000.00 78,722.39!
ICORP Tier 3 DC LTD. 227.44] |Faderal Withholding - Taxable Wages 5,000.00 75,134.21
ICORP Tier 3 DC Legacy ER 13,772.84] |State Tax Taxable Wages - AZ 5,000.00 75,134.21
IDC- CORP ER 2,562.99
ER DHMO-Cigna Dental Care 112.86)
IER UHC HDHP with HSA. 11,399.22
IER Vision 111.76
Employer Paid Benefits 0.00 28,211.80

z deral
Marital Status Single or Married filing) Description Accrued Reduced Availabe:
separately! Floating Personal Day C) i) 0
llowances: 9 2.00%} |Sick - County 0 10 87.25)
Additional Withholding ) O} }Vacation - County 4.65 0 317.97]

(Bank Account Name

Account Number

USD Amount

Amount

(Check)

3,417.50 __USD!

Dorene Tremayne (COB)

ESE 8 SST STE I EES TESS
From: Monica Reyes (MHR)
Sent: Tuesday, May 14, 2024 2:10 PM
To: Dorene Tremayne (COB)
Subject: RE; Affidavit Question
Hi Dorene,
Here is the check number: 3560
89v : SCGEZQXKQOW Campos Aguilar, Edgar 18771
. Check/VoucherNo. ADPCheck Number Type Pages Wrap Print Sequence
000000003560 52755693, Check 2 000000001 224-2211

Thank you,

Monica Reyes
HUMAN RESOURCES
301 W Jefferson, 8" Floor Phoenix, AZ 85003

lL
MAR) Cc fo] PA Payroll Specialist Senior
COUNTY |; a

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From: Dorene Tremayne 0
Sent: Friday, May 10, 2024 3:4
To: Mons Reyes (+

Subject: Affidavit Question

Hello Monica,

Attached is a warrant without a check No. | need this information to process the warrant. Can you please look
into this and respond back to my email so | can get this processed?

Thank you,