STAMPED & REDACTED ANGELA BARRERA LOLI.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Monica Reyes
Date: August 19, 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 ___ Monica at x 6-8051__ for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.

Stale Dated Warrant (Over 1 Year) Duplicate Warrant |

Thank you.

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application is for: oO Duplicate or C1 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.

Dae le Yoarveva Lol (1), being first sworn, upon oath deposes and says:
Name/Claimant ,

On or about d 1% | 202] (date)(2) a warrant/check was issued to the

above named pergon/ehtity 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 issyed to him/her in the sum of $. 1S V¢ 17 (3)
Signed: (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 IS day of Arnon 20_ZI.
Oe 1 viva Q LOD

NOTARY PUBLIC

¥

EILEEN WILLIAMS-PREAS
My commission expires: MARICOPA COUNTY
i-G .2092, _ expires Novornber 8, 2022 (seal)
Warrant/Check Number : i)
(if known) (6) a DPTETY3 FO
Original Date of Issue |
(if known) (7) g I<] 202 |
Reason for original issue of Warrant/Check (8):
O Payroll 08/20/2021
O For Services or Goods furnished -

OO Treasurer's refund/payment
O Other:

Revised April 2015 Cpr for Pidaue ARS, 11-632 & 11-644
WO%. 50S 275K

( Paycheck View

Name Loli,Angela L Barrera Confirmed
Check# Issue Date Earnings Taxes Deductions Net Pay
23074370 08/18/2021 2,337.60 361.16 429.65 1,546.79
r Regular and Overtime Earnings r Taxes
RegHours — Reg Pay OTHours OT Pay | FED SSDisMLVEE 137.55
FED MedicareEE 32.17
20.00 584.40 FED Withholdng 166.32
40.00 1168.80 * FED SS/Dis ER 137.55
* FED MedicareER 32.17)
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross 80 After-Tax 4.56
VAC 20.00 584.40 Y 91B After-Tax 4.27
92 After-Tax 10.22
98B After-Tax 1.00
14 After-Tax 4.44

ADP Enterprise HR screen print as of: 08/19/2021 12:45 PM