STAMPED & REDACTED-ROXANA ROSENTHAL.PDF

Maricopa County
Human Resources

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RECEIVED

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MARICOPA COUNTY
. CLERK BOARD OF SUPERVISORS
To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: February 27, 2025

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 Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 41 08/02/2022

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.

Roxana Rosenthal (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 11/20/2024 (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 $514.50 (3)

Signed: LAr On C~ (Bevan ad (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 te day of Februa rl = 202%.

Love-hine Rollock Pill

TO ee eT emt

NOTARY PUBLIC LAURA ANNE ROLLOCK
NOTARY PUBLIC - ARIZONA
Bail A Maricopa County
My commission expires: Commission # 617620
E My ission Ex!
Zz Be pare, 2085 (seal)
ee an Ant An ini:
Warrant/Check Number
(if known) (6) 53030484
Original Date of Issue
(if known) (7) 11/20/2024
Reason for original issue of Warrant/Check (8):
Payroll
L_IFor Services or Goods furnished
L_ItTreasurer’s refund/payment
(other:
Revised April 2015 A.R.S, 11-632 & 11-644

2/27/25

Maricopa County 301 W. Jefferson Si. Suite 800 Phoenix AZ 85003 +1 (602) 5083519

Roxana Rosenthal

ani

|Maricopa County

State Tax Taxable Wages - AZ

‘Description Dates Hours Rate Amount YTD Hours YTD Amount!
BEingual/Premium Training 1404/2024 - 11/10/2024 1 25 25.00 i 25.00)
[Central Board Workers 10/29/2024 - 11/10/2024 27 16.5 445.50 27 445.50
Election incentive Pay 14/04/2024 - $1/10/2024 22 2 44,00 22 44,00.
Eamings 514.50 514.50:
[Description ” Amount YTD
Federal Withholding - Taxable Wages $14.50 514,50)

$14.50 514,50]

larital Status

\Alowances

(Additional Withholding

Payment Informal

Bank

Account Name Account Number

USD Amount

Amount

Check}

514.50 USD}

v
MARICOPA
COUNTY

Human Resources
Payroll & Employee Records Division

301 W. Jefferson St., 8th Floor
Phoenix, Arizona 85003 DATE: February 27, 2025

P: 602-506-3519

F 602+372-8722 TO: Kristin Storm

Maricopa.gov
FROM: = Zell Bullis

RE: Stop Payment on Warrant

Please place a stop payment on the Warrant listed below. It has been determined
that the Warrant is outstanding as of this date:

Warrant Number: 53030484

Issue Date: 11/20/2024

Payable to: Roxana Rosenthal

Amount: $514.50

Reason for Stop Payment: Employee didn’t receive PR check in the mail.

Zell Bullis

Authorized Signature — Payroll Specialist

Date Stopped aha las, Stopped by ensanStom
Transaction Number Time Stopped | ‘ Situ