STAMPED & REDACTED GLORIA REYES.PDF

Maricopa County
Human Resources

VMemo RECEIVED

AUG 08 2021
. . MARICOPA COUNTY
To: Juanita Garza, Clerk of the Board CLERK BOARD OF SUPERVISORS
From: Linda Greinke Ba lead Dolmad ALE
Date: August 4, 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 Linda at ext. 63770 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 4 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: al Duplicate or XC 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.

Gloria Reyes (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about July 21, 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

warrate/ehec be i) him/her in the sum of $1 036.32 (3)

Signed: . (4)

Note: Please aac Doy 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 3 dayof A — 20 2.

NOTARY PUBLIC

EILEEN WILLIAMS-PREAS
Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 554349 (seal)
Expires November 9, 2022

My commission expires:

Warrant/Check Number
(if. known) (6) 23068466

Original Date of Issue
Se at iaath i) 7/21/2021

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

O For Services or Goods furnished
C1 Treasurer's refund/payment 08/04/2021
O Other:

Revised April 2015

- Reyes,Gloria E - MC1/NEX

( Paycheck View | MCY-Eamings [ Taxes | Deductions [ Garnishments [ SpecialAccumulators | Distributions

Confirmed

Name Reyes, Gloria E
Check# Issue Date Earnings Taxes Deductions Net Pay
23068466 07/21/2021 1,431.20 217.27 177.61 1,036.32
- Regular and Overtime Earnings r Taxes
RegHours _ Reg Pay OT Hours OT Pay FED SSDisMLVEE 88.73
FED MedicareEE 20.75
40.00 715.60 FED Withholdng 85.18
24.00 429.36 * FED SS/Dis ER 88.73)
* FED MedicareER 20.75
~ OtherEarnings ; Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.72
FLT 8.00 143.12 Y 12 Before-Tax 174.89
HPA 8.00 143.12 Y * 57 Nontaxable 16.04
* 90ER Nontaxable 0.57
* Q1ER Nontaxable 0.29

ADP Enterprise HR screen print as of: 08/03/2021 03:38 PM