STAMPED & REDACTED SHAYLEE BEASLEY.PDF

Maricopa County
Human Resources
Memo
To: — Cindy Goelz, Clerk of the Board
From: Linda Greinke
Date: April 6, 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 Linda. at ext. 63770 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.
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Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: [ml Duplicate or C1 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.
Shaylee Beasley (1), being first sworn, upon oath deposes and says:
~~ Name/Claimant
On or about 3/3/2021 (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
ae be issued to him/her in the sum of $ 1337.30 (3)
NY
Signed: tt (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a was originally issued.
warrant/check
Yavch
and sworh before me this 3\S¥ day of 202\.
vay)
NQTARY PUBLIC A Y
pl, CASSANDRA KUSLER
Notary Public - State of Arizona
My commission expires: _ . MARICOPA COUNTY
ay au; day Commiasion # 868818 (seal)
Warrant/Check Number
23048242
(if known) (6)
Original Date of Issue
3/ 3/ 202 1
(if known) (7)
Reason for original issue of Warrant/Check (8):
im Payroll
O For Services or Goods furnished
04/06/2021
O Treasurer’s refund/payment
1 Other:
Revised April 2015

- Beasley,Shaylee C - MC1/EXM
nS Distributions
Name Beasley,Shaylee C Confirmed Check and Advice
Check# Issue Date Earnings Taxes Deductions Net Pay
23048242 03/03/2021 3,557.60 871.93 498.37 2,187.30
Check/Advice# Type Account# Amount
3273492 Checking 665059561: 850.00
Transit#: 122100024
23048242 _Issue Check MO 1,337.30
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Transit#:
ADP Enterprise HR screen print as of: 03/22/2021 03:08 PM