STAMPED & REDACTED KATHY HEEREN.PDF
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Maricopa County Human Resources Memo To: Cindy Goelz, Clerk of the Board From: Zell Bullis Date: May 25, 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. RECEIVED MAY 96 2022 oe SUPERVISORS Replacement Lost Warrant Form 1 04/08/2021 Hone) Sele ye Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or oO 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. Kathy Heeren (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 oe in the sum of $208.00 (3) Signed: (lly A LAP (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 Oooh! this oj a, of seal 20 AD. NOTARY PUBLIC ERIKA SANC NOR COP ae eth My_commission expires: (seal) Mere eon) 231 28297 Original Date of Issue [April 27th, 2022 Reason for original issue of Warrant/Check (8): Payroll C1 For Services or Goods furnished C Treasurer's refund/payment 05/26/2022 O Other: ” Revised April 2015 - Heeren, Kathy Ann MC1 - Maricopa County 2120 - Election Day Services ELE-Elections _| Active 09/02/2008 Temp/PT Off Cycle: N Separate Check # 0 Reprint: N Adjustment: N Company: MC1 Pay Group: ELE Period End 04/17/2022 Page. 913 Line: 5 ff Paycheck View Name. Heeren,Kathy Ann Confirmed Check Check# Issue Date Earnings Taxes Deductions Net Pay 23128297 04/27/2022 208.00 208.00 Regularand Overtime Earnings r Taxes Reg Hours Reg Pay OT Hours OT Pay - OtherEarnings r Deductions Code Hours Amounts Add to Gross EPT 46.00 208.00 Y ADP Enterprise HR screen print as of: 05/25/2022 10:40 AM