STAMPED & REDACTED - NANCY BERGLUND.PDF
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Maricopa County Human Resources To: Juantia Garza, Clerk of the Board From: Zell Bullis Date: January 13, 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. Nancy Berglund (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 $ 457-80 (3) signet 72 aie Boon Oleryrak 2 (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__(o day of SSNS 202), oC Sosa NOTARY PUBLES, DENNIS D THOMPSON aN Notary Public - Arizona By Maricopa County My ission expires: e te, j 578580 ees OV, 2SUMA Wey vy aa pres Mar 1, 2024 (seal) Warrant/Check Number (if known) (6) 52485371 Original Date of Issue (if known) (7) 11/23/2022 Reason for original issue of Warrant/Check (8): [¥]Payroll (For Services or Goods furnished (treasurer's refund/payment (other: Revised April 2015 Maricopa County Phoenix, AZ 85003 [Company y Period: eriod End} Nancy Berglund Maricopa County 10/31/2022) 11/13/2022 Amount YTD Hours YTD Amount} Description Amount [State Tax Taxable Wages - AZ Description Dates Hours Rate YTD) Central Board Work1 1/02/2022 - 11/13/2022 34.25 13 445.25 34.25 445,25] |State Tax - AZ 12.70 12.70| Hazard Pay 14/07/2022 - 11/13/2022 25.25 1 25.25 25.25 25.25) Earnings 470.50 470,50] | Employee Taxes 12.70 12.70, L Taxable Wage Description Amount YTO| Federal Withholding - Taxable Wages 470.50 470.50} 470.50 470.50 Marital Status Single or Married filing separately! Allowances. fy) 0.00%| [Additional Withholding tt) ‘ayment Informati Bank Account Name Account Number USD Amount Amount (Check) 457.80 USD} Maricopa County Human Resources Payroll & Employee Records Division 301 West Jefferson Street Suite 220 Phoenix, AZ 85003-2143 DATE: January 13, 2023 Phone: 602-506-3519 Payroll Fax: 602-372-0277 Records Fax: 602-506-5509 TO: Jessica Kiles — FROM: Zell Bullis RE: Stop Payment on Warrant Please place a stop payment on the Warrant listed below. It has been determined that the Warrant is outstanding as of this date: Warrant Number: 52485371 Issue Date: 11/23/2022 Payable to: Nancy Berglund Amount: $457.80 Reason for Stop Payment: Employee didn’t receive Payroll check in the mail. Attach a print screen of the paycheck view. Gelluor Bullis Authorized Signature — Payroll Specialist Date Stopped Stopped by Transaction Number Time Stopped