REDACTED - FOR AGENDA ATTACHMENT -MOISES CRUZ.PDF
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Maricopa County Human Resources VMemo To: Juanita Garza, Clerk of the Board From: Lisa Platek Date: March 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 Lisa at ext. 63619 for any questions. Please route approved Affidavits back to County Payroll, Suite 800. ace, ae a — (Stal 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: O Duplicate or = 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. Moises Cruz (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 99/ 28/ 2022 (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 $203.29 (3) Signed: Wok SCR. Q << (4) a, Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. is HD day of MOWEh 2024, SAMMIE L. LAKE Nolary Public - State of Arizona My ri expires: MARICOPA COUNTY 20. id Commission # 661507 | Jan 20. Expires January #4, 2020 (seal) HO (50 Warrant/Check Number 0023165022 (if known) (6) Original Date of I rigina & ate of o 09/28/2022 Reason for original issue of Warrant/Check (8): Payroll (1 For Services or Goods furnished, O Treasurer’s refund/payment _ Other: PS Ret Refund Revised April 2015 A.R.S. 11-632 & 11-644 co FILE # 000149-000147 PCSPKA 000066071 5121 811043944 Maricopa County 301 W. Jefferson St. Suife 800 Phoenix, AZ 85003 602-506-3519 Taxable Marital Status: M Federal; 9 State AZ: 3.6% Earnings Statement Period Ending: Check Date: Check Number: Batch Number: Moises Cruz Page 001 of 001 09/18/2022 09/28/2022 0023165022 220140001 Local: 0 Hours/ Earnings Rate Units This Perfod Year-to-Date This Period Year-to-Date PS Ret Ref 210.88 210.88 Tax Withholding AZT Ja ~7 59. ~7.59 S1cK 0.00 0.00 Vacation 0.00 0.00 Float Pers 0.00 0.00 important Notes 602-506-351 Employee Identification Nbr: 811043944 » 301 W.: Jefferson st. “Suite 00° oe aS UST CHANGE Maricopa County. ° as Phoenix, AZ -g6003 ° 602-506-3519 4 5 "Check ‘Number: “Check ‘Date: * "98/28/2022... Pay to the order of. This amount: $**203 -29| Moises Cruz ASSISTANCE WITH VERIFICATION AVAILABLE AT 877-423-7243 Void afier 180 days ADP AUTHORIZED SIGNATURE © 1998, 2006. ADP, INC All Rights Reserved. ORIG ENOUASEMENT. EB W CHECIING THE