STAMPED & REDACTED THOMAS LEIBUNDGUT .PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: April 13, 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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.

Stale Dated Warrant Duplicate Warrant

Thank you.

TACS0~ Be
D Seo

Replacement Lost Warrant Form 1 02/25/2015

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.
Thomas Leibundgut (1), being first sworn, upon oath deposes and says:
“Name/Claimant

On or about __ 3/30/2022 (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 $ 1,421.73 (3)

Signed: (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 Iz day of Aer \ 20°22,

NOTARY PUBLIC

_ ; SEN, EILEEN WILLIAMS-PREAS
My commission expires: (ea: Noten Public Stee a Arizona
WL. %-BOXD. EY _Commianion Fasco10 (seal)
Expires November 9, 2022

Warrant/Check Number
(if known) (6) 23122114

Original Date of Issue
(if known) (7) 3/30/22

04/14/2022

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

OC For Services or Goods furnished
1 Treasurer’s refund/payment
O Other:

empr. pWIeWP
Revised April 2015 lo 23 -3oA U2q 6 A.RS, 11-632 & 11-644

Paycheck View

Name Leibundgut, Thomas Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23122114 03/30/2022 2,153.20 287.86 443.61 1,421.73
r Regularand Overtime Eamings r Taxes
RegHours — Reg Pay OT Hours OT Pay FED SSDisMLVEE 120.31
FED MedicareEE 28.14)
42.00 304.08 FED Withholdng 92.59
38.00 962.92 * FED SS/Dis ER 120.31
* FED MedicareER 28.14)
r OtherEarnings r Deductions
Code Hours Amounts Add to Gross: 82 After-Tax 12.08
BRV 28.00 709.52 Y 91B After-Tax 2.78
HP4 12.00 48.00 Y 92 After-Tax 8.67
SH1 4.00 2.00 Y 98B After-Tax 1.00
HP4 18,00 72.00 Y 100 Before-Tax 25.00

ADP Enterprise HR screen print as of: 04/12/2022 03:42 PM