STAMPED & REDACTED RICHARD D ANDERSON.PDF
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Maricopa County Human Resources Memo RECEIVED To: — Cindy Goelz, Clerk of the Board uN a ae CLERIOARD OF SUPERVISORS From: Zell Bullis low) Dab -AC Date: June 8, 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, Suite 400. Stale Dated Warrant Duplicate Warrant Thank you. Replacement Lost Warrant Form 4 04/08/2021 Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or LJ 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. Richard D Anderson (1), being first sworn, upon oath deposes and says: Name/Claimant On or about April 27th, 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 waramichecte issued to him oo) mot $ 208 (3) Signed: —_ c | Le elugr— ta) al y 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 Ab day of SV une 2022. NOTARY PUBLIC ~~ Pinal County My commission expires: RN Commission # 579248 Fe b f, 20 ZY <i” My Comm. Expires Feb 8, 2024 (seal) MANUEL FERRIGNO Notary Public - Arizona GER 2) ) LY Warrant/Check Number (if. known) (6) 23128198 Original Date of Issue (if known) (7) 4/27/2022 Reason for original issue of Warrant/Check (8): Payroll L_]For Services or Goods furnished L_Itreasurer’s refund/payment 06/09/2022 [_lother: . Revised April 2015 ELE-Elections Active : Anderson, Richard D MC1 -Maricopa County 2120 - Election Day Services 11/08/2016. Temp/PT Company: Pay:Group: Period End. 04/17/2022 Page: Line: MC1 Elie Off Cycle: N Separate Check # 0 Reprint: N 59 Adjustment: N 4 ( Paycheck View [f# Name. Anderson,Richard D Confirmed Check - Check# Issue Date Earnings Taxes Deductions Net Pay 23128198 04/27/2022 208.00 208.00 | Regularand Overtime Eamings Taxes — “| /RegHours RegPay OTHours. OT Pay | ‘¢ OtherEarnings” ——— catauaas Ta el r Deductions Code ~ Hours. Amounts Add to Gross | ERT 2216.00 = --20800 = Yo ADP Enterprise HR screen print as of: 06/08/2022 09:37 AM