STAMPED & REDACTED ANTHONY BACH.PDF

hie Maricopa County
fuman Resources
Teena
Vath
VMemo
To: Fran McCarroll, Clerk of the Board
From: Zell Bullis
Date: March 1, 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 220.
Stale Dated Warrant uplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

2 ee
Application for a Duplicate or Stale-Dated Warrant/Check
th
ee
Affidavit /Claim Form OuNig
This application is for: at Duplicate or J 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.
Ano, ack (1), being first sworn, upon oath deposes and says:
Name/Claimant ¢)
On or about 2 (7 | woZL\ (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 $__ TO& 2 | (3)
don f. Sore KO
Signed: Le Zz (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 i] x day of Merk 20_2/.
yy ee
NOTARY PUBLIC NOTARY PUBLIC
STATE OF ARIZONA
Nai County
My commission expires: MAS ON S § PETERS
03/0e/2gz2 a arth 2, 2022 || (seal)
Warrant/Check Number . 6 bb ; 6
Oor> O4-
(if known) (6)
Original Date of Issue “
2 | (7 | /2orv ;
(if known) (7)
original issue of Warrant/Check (8):
Reason tor
Payroll
03/03/2021
1 For Services or Goods furnished
11 Treasurer’s refund/payment
1 Other:
Revised April 2015 A.R.S. 11-632 & 11-644

- Bach,Anthony J Company: MC1 Off Cycle: N
MC1 - Maricopa County Pay Group: NEX Separate Check # 0
1603 - Financial Svcs and Quality Ctl Period End 02/07/2021 Reprint: N
NEX-NonExempt Page 85 Adjustment: N
Active —s-: 10/07/2019 Reg/FT bine 2
_
-Bach,Anthony J-MC4/NEX
Paycheck View
Name Bach,Anthony J Confirmed Check
Check# Issue Date Earnings Taxes Deductions
23046666 02/17/2021 1,320.80 198.34 216.25
- Regularand Overtime Eamings Sates, Taxes ee
RegHours RegPay OT Hours OT Pay _ FED SSDisMLVEE
_
oo FED MedicareEE
: | FED Withholdng
40.00 660.40
|
FED $S/Dis ER
30.00 495.30
‘ FED MedicareER
:
- OtherEarnings a -Deductions
Code Hours Amounts _Add to Gross 14 After-Tax
_
SCK 1000 tee 43P Before-Tax
42
Before-Tax
* 43PER Nontaxable
* S2ER Nontaxable
ADP Enterprise HR screen print as of: 03/01/2021 01:45 PM