STAMPED & REDACTED BRIAN SCOTT GERBER.PDF

Maricopa County
Human Resources

To: Juantia Garza, Clerk of the Board

From: Zell Bullis

Date: September 1, 2022

(CQ. PEMNAPY—

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 [] 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.

Brian Scott Gerber (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 08/17/2022

(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

werent Se in the sum $1.09) (3)
Signed: a

Z =f WA ZZ (4)

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

(5) Subscribed and sworn ea i ye day of AUAUSK 2032.
O00 mzizth

NOTA BLIC ——

COLLEEN M.
. . Notary Public - Aas = See
commission expires: MARICOPA COUNTY
Q= \ OTR Lo Expires June 10,2020 (seal)
Warrant/Check Number
(if known) (6) 23154552
Original Date of Issue
(if known) (7) 08/17/2022
Reason for original issue of Warrant/Check (8):
Payroll
L_IFor Services or Goods furnished
L_Itreasurer’s refund/payment 8
”
Llother: ; 9
Revised April 2015 = 09/02/2022 A.R.S, 11-632 & 11-6442

MCt- Maricopa County

y ELE-Elections
i Active

11/08/2016: Temp/PT.

- Gerber, Brian Scott

2120 - Election Day Services.

Company; MC4
Pay Group: ELE

| Period End 08/07/2022

Page: 157
Line. 5

Off Cycle: N
Separate Check #0
Reprint. N
Adjustment::N

Name Gerber, Brian Scott

Confirmed Check
Check# Issue Date Earnings Taxes Deductions . Net Pay
23154552 08/17/2022 431.00. : 431,00
“RegularandOverimeEamings = ee Taxes =
Reg Hours Reg Pay ‘OT Hours OT Pay aS
nOtherEamings*=s2a er reser eee een ea ‘» Deductions
Code _ Hours ~ Amounts Add to Gross} as
EPS 18.50 EIB BOS Ye

ADP Enterprise HR screen print as of: 09/01/2022 02:49 PM