STAMPED & REDCATED - FOR AGENDA ATTACHMENT ALEJANDRA ENRIQUEZ GATES.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

81 Ud¥ B202

as prenepyray

From: Zell Bullis
Date: April 18, 2023

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 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

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.
Alejandra Enriquez Gates (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 11/23/2022 (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 We him/her in the sum of $345.90 (3)
(4)

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

Signed:

Nt ed\and sworn to before me this Abe? day of Apt 20 ZA.

NOTARY PUBNC! ONotmry Public
Maricopa County, Arizona
My commission expires: K <] My Comm. Expires 2-8-2025
316 [000 ‘ Commission No. 596694 (seal)
Warrant/Check Number
(if known) (6) 52486497
Original Date of Issue
(if known) (7) 11/23/2022
Reason for original issue of Warrant/Check (8):
Payroll
ror Services or Goods furnished
LItreasurer’s refund/payment
_Jother:
4/18/2023

Revised April 2015

Maricopa County _ 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003_+1 (602) 5063519

Company Employes 1D} y Period Begin] Pay Period End} heck Date|_ Check Number

Gates Enriquez Gates Maricopa County 10/31/2022 41/13/2022) 11/23/2022!
d ra Tax Deductions|

(Current 0.00 0.00
YTD 0.00} 0.00)
Description Dates Hours, Amount YTD Hours YTD Amount} |Description Amount
Bilingual/Premium 14 1/07/2022 - 11/13/2022 1 25 25,00 1 25.00] |State Tax - AZ 9.60 9.60)
(Central Board Work1 1/02/2022 - 11/13/2022 24.25 13 315.25 24,25 315.25)
Hazard Pay 41/07/2022 - 11/13/2022 15.25 1 45.25 15.25 15.25
Earnings 355.50 355.50] | Employee Taxes 9.60 9.60

Amount YTD

Description
Federal Withholding - Taxable Wages 365.50 355.50
355.50 355.50

[State Tax Taxable Wages - AZ

Marital Status
[Allowances
(Additional Withholding

iBank ; Account Name Account Number USD Amount Amount
(Check) 345.90 __USD