Extracted text (via ocr_local)
3254 characters
BQABY nse
Maricopa County
Human Resources
9923 FEB -8 PH 2:24 |,
ond Darwery
To: Juantia Garza, Clerk of the Board
From: Zell Bullis
Date: February 8, 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 LI 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.
Daniel Gonsowski (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
ones be issued to him/her in the sum of $399.42 (3)
mul Jodo (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:
(5) Subscribed and sworn to before me this _o2nel_day of _Ecb. 2023.
NOTARY PUBLAC
BETHANY L. RICHARDSON
© Notary Public - State of Arizona
My commission expires:
MARICOPA COUNTY
Feb. /¢ ,202l0 Comission # 622711 (seal)
Expires February 14, 2026
Warrant/Check Number .
(if known) (6) 52487122
Original Date of Issue
(if known) (7) 11/23/2022
Reason for original issue of Warrant/Check (8):
Payroll
[For Services or Goods furnished
LItreasurer’s refund/payment
(other:
2/9/2023
Revised April 2015
St. Suite 800 Phoenix, AZ 85003
+1 (602) 5063519
Employee 1D) ay Period Bagin!|
~ Pay Period Er
Check Date] Check Number
811146125 10/31/2022{
14713/2022]
14/23/2022
- Pre Tax Deductions|
0.00]
0.00]
Description Dates. Hours. Rate Amount YTD Hours YTD Amount} |Description Amount YTD!
[Central Board Work1 1/02/2022 - 11/13/2022 29.75 13 386.75 29.75 386.75] [State Tax - AZ 11.08 11.08
Hazard Pay 11/07/2022 - 11/13/2022 23.75 1 23.75, 23.75, 23.75)
Earnings 410.50 410.50] | Employee Taxes 11.08 11.08
: “Taxable Wages
Description Amount YTD|
Federal Withholding - Taxable Wages 410.50 410.50}
State Tax Taxable Wages - AZ 410.50 410.50}
: = Federal
Marital Status Single or Married filing separately|
Allowances i) 0.00%
dditional Withholding 9}
ayment Informati
Bank
Account Name
Account Number
Amount
(Check)
399.42 _USD!