STAMPED & REDACTED-JENNIFER BRIAN.PDF

Maricopa County
Human Resources

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To: Juantia Garza, Clerk of the Board GS S
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From: Zell Bullis
Date: March 6, 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 4 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.
Jennifer Brian (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 replacentent

warrant/check be issued to him/her in the sum of $369.00 (3)

Signed: Pule~—— (4)

Note: pirete attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

rato before me this S*~ day of L US 20_4S,

RAQUEL SOTO
My cg OUSE ires: GIARIGOPA COUNTY
£:L2- dey ge 19, 2028 (seal)
Warrant/Check Number
(if known) (6) 53030450
Original Date of Issue
(if known) (7) 11/20/2024

Reason for original issue of Warrant/Check (8):
[Payroll
[_lFor Services or Goods furnished 3/6/38
[Htreasurer’s refund/payment

other:

SOYOIY/ TI

Revised April 2015 rH . ane A.R.S, 11-632 & 11-644

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003 _ +1 (602) 5063519
Jennifer Bian

Kurent 0.00 360.00 0.00 0.00 0.00 360.00]
rp 0.00 083.62 0.00 0.00 0,00 983.62

iDescription Dates Hours Rate Amount YTD Hours YTD Amount
(Central Board Workers 40/28/2024 - 11/10/2024 20 16.5 330.00 54.25 895.12}
Election Incentive Pay 41/04/2024 - 11/10/2024 45 2 30,00 44,25 88.50
Eamings 366,00 983.62!
[Description ‘Amount YTD
iFederal Withholding - Taxable Wages 360.00 983.62}
[State Tax Taxable Wages - AZ 360.00 983.62

Jarital Status :
llowances.
[Additional Withholding

iBank " Account Name Account Number USD Amount Amount
(Check) 360,00 USD!

v
MARICOPA
COUNTY

Human Resources
Payroll & Employee Records Division

301 W. Jefferson St., 8th Floor
Phoenix, Arizona 85003 DATE: March 6, 2025

P: 602-506-3519
F: 602-372-8722 eae
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: 53030450.

Issue Date: son

Payable to: Jennifer Brian

Amount: $360.00

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

Zell Bullis

Authorized Signature — Payroll Specialist

Date Stopped Aas Stopped by Kastor. fanz
Transaction Number N a Time Stopped { ARAM

Stop Check

@ 1check(s) stop request has been successfully submitted.

Successful checks - 1

Check Number

0000053030450

Pay Date

11/20/2024

Employee Name

Brian, Jennifer E

Amount

$360.0

Your stop payment request has been
submitted. If successful, this
transaction will not adjust employee
YTD wages in your payroll system.
Adjust your payroll system if this stop
payment affects employee YTO
wages,