STAMPED & REDACTED - TERRY PREISS _52962468.PDF

Maricopa County
Human Resources

Viemo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: January 23, 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 1 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: 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.
Terry Preiss .
si lina (1), being first sworn, upon oath deposes and says:
On or about 8/14/2024 (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 $1537.64 (3)

Signed: Jinney Prune (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__? "day of J anvany 20_2S.

Aprur O30
NOTARY PUBLIC
Ashiee J Ganilla
My commission expires: © Macoopa County zona
| Or|2%u]2024 Me ten Saaee (oesl)
Warrant/Check Number
(if known) (6) 52962468

Original Date of Issue

9 (if known) (7) 8/14/2024

Reason for original issue of Warrant/Check (8):
[Payroll

(For Services or Goods furnished
(Treasurer's refund/payment
Clother:

1/24/25

Revised April 2015 AK, 11-52 & 11-044

co
89V
2120

100542-000542

Maricopa Counly
301 W. Jefferson St.

Suite 800

Phoenix, AZ 85003

For inquiries on this

statement please call:

602-506-3519

Earnings Statement

Employee ID 811145712
Page 001 of 001
Period Beg/End: 07/22/2024 - 08/04/2024
Check Date: 08/14/2024
Check Number: 0052962468
Batch Number: SCGQSDHQK8KD

Terry Preiss
995 E Baseline 9 #2048
Tempe, AZ 85283

Total Hours Worked: 0.00
Basis of Pay: Hourly
Pay Rate: 12.15 "
Hours/ This Other This
Rarnings Rate Units _Period Year-to-Date Deductions Period Year-to-Date
Central Boar 14.5000 72.25 1047.62 3222.61
Election Inc 2.0000 67.25 134.50 175.00
Incentive Pa 2.0000 21.00 63.00 63.00
Central Boar 14.5000 21.00 456.75 831.95
Gkoee Pay: ; Te EIOE 87 Gage 56
Taxes
Medicare 24.67 62,24
OASDI 105.52 Z
State Tax - AZ 34.04
nie kee

Total taxes:

Your Federal taxable wages for this period are:

mAOOCUME NT AU Pla Nery

GRE

£290"

aN MUSE SANNSES IN TONE

$1,701.87

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*Excluded from taxable wages <
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©2017 ADP, LLC (PCSUCH)
LET AND SYENES FOU Oso NT SORES Elcis LAr eo BOOM t})

90-477/1222 CA

Check Number: 0052962468

Check Date: 08/14/2024

© 1998, 2006. ADP, INC All Rights Reserved.

This amount:

ONE THOUSAND FIVE HUNDRED THIRTY SEVEN DOLLARS AND 64/100

$°"1,597.64 |

ew

Pay to the
order of:

ASSISTANCE WITH VERIFICATION AVAILABLE AT 877-423-7243
Void after 180 days

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ADP AUTHORIZED SIGHATURE

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