STAMPED & REDACTED - JULIA FARNSWORTH.PDF
Extracted text (via ocr_local)
2958 characters
Maricopa County Human Resources VMemo To: Juantia Garza, Clerk of the Board ern? From: Zell Bullis Date: January 19, 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. oF Replacement Lost Warrant Form 1 08/02/2022 “Fiona pwnd Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or CI 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. Julia Farnsworth (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 1/4/2023 (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 $97.29 (3) Signed: Ole LA yor. 21le_, (4) Note. Pledse 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 \2k" day of Jai 2023. own bear ‘ NOTARY PUBLIC My commission expires: ©) woe hte l | LAIZ202S. eo yon erie (seal) Warrant/Check Number (if known) (6) 52521916 Original Date of Issue (if known) (7) 11/23/2022 Reason for original issue of Warrant/Check (8): Payroll [_]For Services or Goods furnished L_]Treasurer’s refund/payment other: Revised April 2015 1/23/2023 Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003 Julia Famsworth Nam ployee ID] Pay Period | Pay Patiod End] Julia Famsworth L 12/12/2022} 12/25/2022 (Current 0.00; 0.00 YTD 0.00} 0.00 aming: Description Dates Hours Rate Amount YTD Hours YTD Amount! \Central Board Workers 12.80 12/19/2022 - 12/25/2022 812.15 97.20 8 97.20 Eamings 97.20 97.20) Description [State Tax Taxable Wages - AZ |Federal Withholding - Taxable Wages 97.20 97.20 97.20 97.20 aS g Federal Marital Status Single or Married filing separately| Allowances 0) [Additional Withholding Bank Account Name Account Number USD Amount Amount (Check) 97.20__USD