STAMPED & REDACTED LEANN K. WALLS.PDF

Maricopa County
Human Resources

Memo : =

To: Cindy Goelz, Clerk of the Board

From: Zell Bullis
Date: May 16, 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.

— Y

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 04/08/2021

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Bd Duplicate or CI 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.

Leann Kay Walls
Name/Claimant

On or about __ 04/27/2022 (date)(2) @ 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.

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

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 $1121.29 (3)

Signed: Leann Kay Walls Atebble (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 ran Diced before r- this_ 124” day of May 2022.

NOTARY PUBLIC ~\~ CAMILLE EHLERT

BY, Notary Public, State of Arizona
My commission expires: _
Polonia |) 1202L

Commission # 620298
My Commission Expires
February 10, 2026 (seal)

Maricopa County
t

Warrant/Check Number
(if known) (6) 23128466

Original Date of Issue
(if known) (7) [27/20

nny ae original issue of Warrant/Check (8):
Payroll

(1 For Services or Goods furnished___

O1 Treasurer's refund/payment

CJ Other: 05/19/2022

Revised April 2015

-Walls,LeannK _ Company MC1 Off Cycle: N
MC1-Maricopa County Pay Group: NEX Separate Check #. 0
2201 - Pandemic Relief Funding _- Period End 04/17/2022 Reprint: N
NEX-Non Exempt | Page: 271 Adjustment: N
Active 04/01/2022 Reg/FT : | Line: 2

( Paycheck View

Name Walls,Leann K Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23128468 04/27/2022 1,440.00 140.00 178.71 1,121.29
, Regularand Overtime Earnings |p Taxes :
RegHours. Reg Pay OT Hours OT Pay FED SSDisMLVEE 89.28
FED MedicareEE 20.88
FED Withholdng 7.09
© FED SSIDis ER 89.28
14.50 261.00 * FED MedicareER 20.88
r OtherEarnings fi Deductions
Code Hours Amounts Add to Gross 14 After-Tax 2.74
VAG 5.50 99.00 Y 12 Before-Tax 175.97
VAG 2.75 49.50 Y * 412 Nontaxable 175.97
VAC 2.75 49.50 Y 14 Nontaxable 2.74
VAC 437 78.66 Y

ADP Enterprise HR screen print as of: 05/16/2022 10:44 AM