STAMPED & REDACTED STACEY SHANNON.PDF
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Maricopa County Human Resources Memo : To: Juantia Garza, Clerk of the Board From: Zell Bullis pa Date: August 12, 2022 & 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. Stacey Shannon (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 $2339. 14 (3) Signed: Dha of Ee 2 Siena (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 1O day of Ulawat 2022, set. MARGARET JOHNSON Notary Public ~ Arizona Maricopa County Commission # 586211 My Comm. Exp. August 05, 2024 NOTARY (seal) My TSS jres: + Original Date of Issue—— 8/3/2022 Warrant/Check Number | 123151550 b= (it known (6)-———— (if known) (7) Reason for original issue of Warrant/Check (8): @ Payroll C1 For Services or Goods furnished C] Treasurer's refund/payment = 08/15/2022 1 Other: A Ul wit jae Revised April 2015 EXM-ExemptEEs | Active - Shannon, Stacey E MC1 - Maricopa County 3750 - Teaching and Learning 07/01/2022 Reg/FT Company: MC1 Pay Group: EXM Period End 07/24/2022 Page 329 Line: Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N - Shannon,Stacey E - MC4/EXM_ ( Paycheck View Name Shannon,Stacey E Confirmed Check# Issue Date Earnings Taxes Deductions Net Pay 23151550 08/03/2022 3,440.00 682.21 418.65 2,339.14 Regularand Overtime Earnings r Taxes 5 RegHours — Reg Pay OT Hours OT Pay FED SSDisMLVEE 213.28 FED MedicareEE 49.88 40.00 1720.00 FED Withholdng 264.72 40.00 1720.00 * FED SS/Dis ER 213.28 * PED MedicareER 49.88 r OtherEarnings ; 7 Deductions Code _ Hours Amounts Add to Gross \ 14 After-Tax 4.82 12 Before-Tax 413.83 * 412 Nontaxable 413.83 to 44 Nontaxable 4.82 ADP Enterprise HR screen print as of: 08/12/2022 01:44 PM