STAMPED & REDACTED - AMY FOREMAN.PDF

Maricopa County
Human Resources

JAN 26 2023

To: Juantia Garza, Clerk of the Board MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

From: Zell Bullis
Date: January 25, 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

g
ond

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/ Claim Form

This application is for: 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.

Amy Foreman (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

416.53
warrant/check be issued to him/hef)in the sum of $489:7> (3)

Signed: BE oe _> (4)

ach a copy of the warrant/check if available and/or any other
oldence that a “warrant/oheck was originally issued.

(5) Subscribed and sworn to before me this 246" day of Jan vany 20, 23

Paromnesdohlompeyn?

NOTARY PUBLIC neRANCES 3 HANSON
of Arizon@
barter
My commission expires: y ane
Feb 323) 20: Desa
Warrant/Check Number
(if known) (6) 52485889
Original Date of Issue
(if. known) (7) 11/23/2022
Reason for original issue of Warrant/Check (8):
lv] ¥ |Payroll
L_IFor Services or Goods furnished
L_Itreasurer’s refund/payment y 1/31/2023
other: i

Revised April 2015

Pay Period Begin}

Amy Foreman Maricopa County 10/31/2022]

(Current

\YTD 0.00

Description Dates Hours Rate Amount YTD Hours YTD Amount} |Description Amount YTD!
\Central Board Work11/02/2022 - 11/13/2022 33.25 14 465.50 33.25 465.50} [State Tax - AZ 13.22 13.22
Hazard Pay 11/07/2022 - 11/13/2022 24.25 1 24.25 24.25 24.25)

Eamings 489.75 489.75} | Employee Taxes 13.22 13.22

faxable Wage:

Description Amount YTD
Federal Withholding - Taxable Wages 489.75 489.75)
[State Tax Taxable Wages - AZ 489.75 489.75}

Marital Status Single or Married filing separately|
Allowances ti) 0.00%
Additional Withholding i)
Payment Information
iBank Account Name Account Number USD Amount Amount
(Check) 476.53 USD