STAMPED & REDCATED - FOR AGENDA ATTACHMENT - LAWRENCE KAHN_REDACTED.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: April 11, 2023

Re: Replacement of Lost Payroll Warrants

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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 Zell Bullis at ext. 60409 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 08/02/2022

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Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: Duplicate or L] 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.
Lawrence Kahn (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 8/17/2022 (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 $ 298.75 (3)
Signed: by =) Kalb (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 14 ft day of Wawid— _ 20.22.

NO, U BIC / ; CATHERINE ESPARZA
Notary Public - Arizona
@ narca

My commission expires: My Comm, Expires Jul 19, 2024

LZ, / 14) [24 (seal)
<= —

(if known) (6) 23154854
Original Date of Issue

(if known) (7) 8/17/2022

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

_IFor Services or Goods furnished

LItreasurer’s refund/payment
(_lother:

Revised April 2015 / 4/14/2023 A.R.S. 11-632 & 11-644

07/26/2022 TempiPT.

i. Kaho,Lawrence Stephen Company: MC1 Off Cycle:
Ct - Maricopa County Pay Group: ELE Separate Check # 0
2120 - Election Day Services Period End: 08/07/2022 Reprint:
ELE - Elections Page: 2337 ‘Adjustment: N

Name: Kahn,Lawrence Stephen Confirmed Check
Checks Issue Date Eamings Taxes Deductions Net Pay
23154854 og/t72022 298.75 298.75
- Regular and Overiime Earnings] Taxes:
RegHours RegPay OT Hours «OT Pay
- Other Earnings SrA —— Deductions <a
Code ‘Hours Amounts Add to Gross,
EPS 15.25 15.25 Y
ETO 20.25 283.50 Y