STAMPED & REDACTED - RICHARD KEARNEY.PDF

Maricopa County
Human Resources

Memo 3

To: Juantia Garza, Clerk of the Board

From: Zell Bullis 2 i
Date: January 19, 2023 7 re)
Re: Replacement of Lost Payroll Warrants Be

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. ek

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 _] 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.

Richard Kearney (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 va to_him/her in the sum of $543.00 (3)

Ih
Signed: “Lad D2 vty RLM Apr th> (4)

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

(5) wai and swornto before“pe this hay of Jon. 2024.

d 4
BIGAICLIM
NOTARY PUBLIC / J Notary Publis Arizona
E Maricopa Count
My commission expires: Fo aber 27, 2024
OF 2k ZO: 7 Ny Como. COeaTy
Warrant/Check Number
(if known) (6) 52486806
Original Date of Issue
(if known) (7) 11/23/2022
Reason for original issue of Warrant/Check (8):
Payroll
L_IFor Services or Goods furnished
I Treasurer’s refund/payment

Revised April 2015

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

Richard Keamey

may Period End

Check Datel Check Number|

10/31/2022]

11/13/2022} 11/23/2022]

Description Hours Amount YTD Hours YTD Amount
\Central Board Workers 15 40/31/2022 - 11/43/2022 34.5 15 517.50 67.5 1,012.50)
Hazard Pay 41/07/2022 - 11/13/2022 25.5 1 25.50 49.5 49.50)
Earnings 543.00 1,062.00

Amount YTD}

Description
Federal Withholding - Taxable Wages 543.00 1,062.00)
[State Tax Taxable Wages - AZ 543.00 1,062.00)

Marital Status

Single or Married filing separately|

Allowances 0 0.00%
Additional Withholding i) 0)
iyment Information. —

|Bank

Account Name

Account Number.

USD Amount

Amount _\

(Check)

543.00 _ USD.