STAMPED & REDACTED - FOR AGENDA ATTACHMENT -DAVID MONJE.PDF

Maricopa County
Human Resources
Memo
To: Juantia Garza, Clerk of the Board
From: Zell Bullis
Date: January 23, 2024
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. q ERG we
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Replacement Lost Warrant Form 1 08/02/2022
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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.
David Monje (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/08/2023 (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 $98.95 (3)
Signed: Dez Dy 29,0 (4)
Note, Please attach a copy y OF the warrant/check if available any other
and/or
evidence that a warrant/check was originally issued.
/ 7 : OY
(5) to before me this day,of Anuar
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NOTARY PuRLIC _) MARIELA MILLANES
<> baat te sO
ricopa Coun
igsio ir Commission # 654560
a
Number
52764703
(if known) (6)
Original Date of Issue
11/08/2023
(if known) (7)
Reason for original issue of Warrant/Check (8):
[V] Payroll
L_IFor Services or Goods furnished
L_ITreasurer’s refund/payment
[_lother: 1/23/2024
Revised April 2015

Maricopa County 301 W. Jeffers on St. Suite 800 Phoenix, AZ 85003 +1 (602) 5063519
David
Current 96.95)
YTD 96.95
Description Dates Hours Rate Amount YTD Hours YTD Amount
Central Board Workers 13.85 10/16/2023 - 10/29/2023 7__ 13.85 96.95 7 96.95
96.95 96.95
Earnings
Description Amount YTD
Federal Withholding - Taxable Wages 96.95 96.95
State Tax Taxable Wages - AZ 96.95 96.95
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Single or Mamnied filing separately
Account Name Account Number USD Amount
(Check) 96.95 _USD|