STAMPED & REDACTED NAVY ANDERSON.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board =

From: Zell Bullis =
Date: August 12, 2022 a

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

H% 480-C84-s1INa

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.
Navy Anderson (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 8/3/2022 (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

warrant/check be issued to him/her in the sum of $ 326-32 (3)

Signed: —Pargnkt-denoer (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 \2 day of Pract 2022.

deen. WUWbinn (Seo

ee PUBLIC

FILEEN WILLIAMS-PREAS
Bane, la
My commission expires: _MeIGOPA COUNTY
| (-G-2e32d Expires November 9, 2022 (seal)
Warrant/Check Number
(if known) (6) _124\50 4g SSS
Original Date of Issue
(if known) (7)

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

Iv] Payroll

L_IFor Services or Goods fu mished_ = 08/15/2022

L_Itreasurer’s refund/payment je UGK tal yh a

other:

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

}20) E.Mckellipe Ra. Mega, AZS9A03

Cott pyr PICle ue —

MC1.-Maricopa County.
2140 - Early Voting Services
NEX-Non Exempt

Active

~ Anderson,Navy M

07/13/2022. Temp/PT

Company: MC1

Pay Group: NEX
Period End 07/24/2022

Page). 225

Line:

A

Off Cycle: N

Separate Check #0.
Reprint: N

Adjustment: N

( Paycheck View

Check

ode Hous 2 7. “vMmounts

Name Anderson,Navy M Confirmed
Check ~~ Issue Date Earnings Taxes Deductions Net Pay
23150948 08/03/2022 364.00 37.68 326.32
: ~ Regularand Overtime Earnings — a cea Taxes -—— — ; :
RegHours RegPay  OTHcurs: OT Pay. FED SSDisMLVEE 22.57)
: : FED » MedicareEE 5.28)
4.00 56.00 * FED. Ss/Dis ER 22.57,
22.00 308:00 MedicareER 5.28
i Withholdng 9.83
r-OtherEarnings: : i
Add to Gross}

ADP Enterprise HR screen print as of: 08/12/2022 01:43 PM