STAMPED & REDACTED BARBARA ANN BARLETT.PDF
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eee “) Human Resources eI HAY -7 PH b: 26 then Doli Vviemo To: Cindy Goelz, Clerk of the Board From: Zell Bullis Date: May 7, 2021 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, Suite 400. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 1 04/08/2021 Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: io Duplicate or CL) 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. Barbara Ann Bartlett (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 11/25/2020 (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 $ 1,591.04 (3) Barbara Ch Batlet Signed: (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 S day of _ May 20. 2/.. NOTARY PUBLIC Spe Rot Al a et j ‘ BRIAN VARELA My commission expires: wvheieepa Coan 02 (0F /Zoz2h fy Comm. Expires Feb 7, 2022 (seal) Warrant/Check Number a 23033863 (if known) (6) Original riginal Date of I Date of Issue | 4 4/25/2020 Reason for original issue of Warrant/Check (8): Payroll O For Services or Goods furnished 05/10/2021 C1 Treasurer’s refund/payment ef Other: W\ laced Sp Revised April 2015 A.R.S, 11-632 & 11-644 - Bartlett, Barbara Ann ' Company: MC4 Off Cycle: N- | MC‘ -Maricopa County ~ PayGroup: ELE - Separate Check # 0 | 2120 - Election Day Services - Period End 11/15/2020 eee Reprint: N.. | ELE- Elections anes a : . Adjustment: NN. Aetive’ = 11/04/2008 TemoPT ae ( ener View _ Name Bartlet, Berbara Ann ~ Check# Issue 5 1 32 1 1 2 594 780 114 86 70.483826 Date 4 1 32 1 2 0 456 856 218 87 -1 5 1 32 1 2 1 456 856 29 63 73.189049 2 5 1 32 1 2 2 496 864 178 79 73.070358 1/25/2020 2 1 33 0 0 0 880 783 171 99 -1 3 1 33 1 0 0 880 783 171 99 -1 4 1 33 1 1 0 880 783 171 99 -1 5 1 33 1 1 1 880 783 171 99 66.507919 Eamings 2 1 34 0 0 0 951 859 222 91 -1 3 1 34 1 0 0 951 859 222 91 -1 4 1 34 1 1 0 951 859 222 91 -1 5 1 34 1 1 1 951 868 47 82 27.993568 fl 5 1 34 1 1 2 1004 868 87 66 22.061726 (738. 5 1 34 1 1 3 1093 859 80 87 66.985802 50 2 1 35 0 0 0 1175 674 543 110 -1 3 1 35 1 0 0 1175 674 543 110 -1 4 1 35 1 1 0 1175 674 543 110 -1 5 1 35 1 1 1 1175 690 19 62 11.394310 - 5 1 35 1 1 2 1205 691 187 93 52.177433 Confirmed 5 1 35 1 1 3 1539 674 179 105 45.607571 “Check 2 1 36 0 0 0 1696 772 264 104 -1 3 1 36 1 0 0 1696 772 264 104 -1 4 1 36 1 1 0 1696 772 264 104 -1 5 1 36 1 1 1 1696 772 264 104 40.940880 Deductions yes ie | 23033863 ae 46 ~ 1,591.04 a “Regular and Overtime Eamings = a Taxes Reg Pay OT Hours ~ §8DisMLVEE 2149.54] Bes tows _MedicareEE -$SiDis ER SE SRED 27.95) Xe OtherEamings ! - Deductions Code) ne Hours os: Amounts - ~ Add to Gioss _ 1927. 50 eo laa : eee -EPW 101.00. ADP Enterprise HR screen print as of: 05/07/2021 11:30 AM