STAMPED & REDACTED - MERRI ZOHAR.PDF
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Maricopa County Human Resources Memo 3 To: Juantia Garza, Clerk of the Board | OZ NYT £202 oo I 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 ot 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 _] 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. Merri Zohar (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 isgu /him/her in the sum of $ 460.00 (3) (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: Dyed and Le Before this 11M day of Caniusiny 2023, GER CHRISTINA LA ZARE | 12 Natary Public - Arizona ei Maricopa County My comm} sion les We sy Comm Expires dan 21,2023 JU . (seal) L Eo Number (if known) (6) 52485640 Original Date of Issue (if known) (7) 11/23/2022 Reason for original issue of Warrant/Check (8): Payroll |_IFor Services or Goods furnished LItreasurer’s refund/payment 1/23/2023 _lother: ; Revised April 2015 Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003 Merri Zohar Nat [Company mployee 1D] Pay Period Beg Merri Zohar Maricopa County [ 10/31/2022} Description Dates Hours Rate Amount_YTD Hours YTD Amount Central Board Workers 13 10/31/2022 - 11/13/2022 33.5 13 435.50 33.5 435.50 Hazard Pay 41/07/2022 - 11/43/2022 24.5 1 24.50 24.5 24.50) Eamings 460.00 460.00 Description Federal Withholding - Taxable Wages [State Tax Taxable Wages - AZ 460.00) 460.00 larital Status Single} \Allowances 0} 0.00% Additional Withholding te) i) Bank Account Name Account Number USD Amount Amount (Check) 460.00__USD|