STAMPED & REDACTED - BRANDAN BENNETT.PDF

Maricopa County
Human Resources

Meno”

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: February 1, 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 LJ 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.
Brandan Bennett (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 be issued to him/her in the sum of $ 365-50 (3)
Signed: (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) S ribed and sworn to before me this Z. ? day of Denmeag 20 aS.
Co C27

NOTARY PUBLIC

KARL HENRY WEISS)
Notary Public - Arizona

My commission expires:

fpr
Y eee

re" = MARICOPA COUNTY
4 “4-25 Vy Commission # 601187 (seal)
Sgit"_Expiras Apiil 4, 2025
Warrant/Check Number
(if known) (6) 52487016
Original Date of Issue
(if known) (7) 11/23/2022

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

[For Services or Goods furnished
treasurer's refund/payment
Lother:

2/2/2023

Revised April 2015

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003
Brandan Bennett

eriod Begin

[company : I
10/31/2022] 11/43/2022

[Maricopa County

Description Dates ; Hours Rate YTD Amount}
\Central Board Workers 13 10/31/2022 - 11/13/2022 26.25 13 341.25 26.25 341.25
Hazard Pay 44/07/2022 - 11/13/2022 24.25 1 24.25 24.25 24.25)
Earnings 365.50 365.50
Description Amount YTD
Federal Withholding - Taxable Wages 365.50 365.50

365,50 365.50}

[State Tax Taxable Wages - AZ

Marital Status Single or Married filing separately!
[Allowances {t) 0.00%
Additional Withholding 0} 0

=
Account Name

USD Amount ; Amount
365,50__USD}

Bank
(Check)