STAMPED & REDACTED - SERGIO JIMENEZ.PDF

Memo

Maricopa County
Human Resources

To: Juantia Garza, Clerk of the Board

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

Thank you.

Replacement Lost Warrant Form

Duplicate Warran

Of

08/02/2022

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/ Claim Form

This application is for: Duplicate or L1 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.

Sergio Jimenez (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 $ 1634.73 (3)

Signed: SS ONAN Ae SL (4)

Note: Please attach ve of the\wartant/check if available and/or any other
evidence that a warrant/check was origirfally issued.

PUBLIC /

*My commission expires:
Biel DypnaNe
———e

Warrant/Check Number
(if known) (6) 52485386

(5) ym to before me this ah day of ated — 20. #2.
_
YU NN —
N RY

Original Date of Issue
(if known) (7) 11/23/2022

Reason for original issue of Warrant/Check (8):
Payroll

| For Services or Goods furnished,

[_Itreasurer’s refund/payment
[_lother:

Revised April 2015 1/23/2023

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

|Compar
IMaricopa County

ay Period E
11/13/2022|

|Current 0.00 1,808.00 173.27 0.00) 1,634.73
YTD 0.00 2,265.00) 173.27 0.00} 2,091.73)
[Description Dates ‘Hours Rate Amount YTD Hours YTD Amountj |Description Amount YTD
Bilingual/Premium 111/07/2022 - 11/13/2022 4 25 25.00 2 50.00} JOASDI 140.43 140.43}
Central Board Work10/3 1/2022 - 11/13/2022 93.5 13 1,215.50 125 1,625.00} |Medicare 32.84 32.84)
Central Board Work10/3 1/2022 - 14/13/2022 23 13 448.50 23 448.50!
Hazard Pay 11/07/2022 - 11/13/2022 84.5 4 84.50 107 107.00
Hazard Pay OT _ 10/31/2022 - 11/13/2022 23 1 34.50 23 34.50}
Eamings 1,808.00 2,265.00] | Employee Taxes 173.27 173.27

faxable Wa:

Description

Amount YTD

(OASDI - Taxable Wages

Medicare - Taxable Wages

Federal Withholding - Taxable Wages
[State Tax Taxable Wages - AZ

2,265.00 2,265.00)
2,265.00 2,265.00)
1,808.00 2,265.00
4,808.00 2,265.00)

dera
Marital Status. Single or Married filing separately!
lowances te) 0.00%
\dditional Withholding iy iy

Bank Account Name Account Number

USD Amount Amount,

(Check)

4,634.73 USD