STAMPED & REDACTED - FOR AGENDA ATTACHMENT - DAVID FEIRING.PDF

Maricopa County
Human Resources

Vemo

To: Juantia Garza, Clerk of the Board

EE: Hd 42 190 F202

From: Zell Bullis
Date: October 24, 2024

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

Mey pudu

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

Name/Claimant

On or about 8/14/2024 (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

ay to him/her in the sum of $ 313-60 (3)
s\
Signed: __ Z/! fas oe (4)

Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

ayyra
(5) Subscribed and sworn to before me this _ 0 day of _ Octphee 20247.

ZL. By

NOTARY PUBLIC” CERT MARTY
Notary Public Stato ie nate
My commission expires: AR OPA 383008
Jul ¥ Cae ALO’? Explres July 24, 2027 (seal)
Warrant/Check Number
(if. known) (6) 52962365
Original Date of Issue
(if known) (7) 8/14/2024
Reason for original issue of Warrant/Check (8):
Payroll
LJ For Services or Goods furnished.
L_Itreasurer’s refund/payment 10/23/24

| Other: i

Revised April 2015

Ware:

David Fairing

laricopa County

"ay Period Begin}

Pay Perod Bhd]

Check Date}. Check Number

08/04/2024

08/14/2024

07/22/2024]

——

(Current 0.00} 0.00) 6.40
NTO 0,00] 0.00) 8.71

Description Dates Hours Rate Amount YTD Hours YTD Amount] [Description " Amount YTO}
(Central Board Work07/22/2024 - 08/04/2024 20 14.5 290.00 27 391.50] {State Tax - AZ 6.40 8.71
Election Incentive PO7/29/2024 - 08/04/2024 18 2 30.00 22 44.00)

Eamings 320.00 435,50} | Employee Taxes 6.40 8.7%
(Description Amount YTD}
Federal Withholding - Taxable Wages: 320,06 435.50}
State Tax Taxable Wages - AZ 320.00 435.50}

Single or Married filing separately!

(Check)

arital Status
Allawances b) 6.00%
Additional Withholding Q
[Bank Account Name. Account Number USD Amount Amount
343.60 ___ USD}

v
MARICOPA
COUNTY

Human Resources
Payroll & Employee Records Division

301 W. Jefferson St., 8th Floor
Phoenix, Arizona 85003 DATE: October 24, 2024

P: 602-506-3519
F: 602-372-8722 woe
TO: Kristin Storm

Maricopa.gov

FROM: = Zell Bullis

RE: Stop Payment on Warrant

Please place a stop payment on the Warrant listed below. It has been determined

that the Warrant is outstanding as of this date:

Warrant Number; 52962365
Issue Date: _ 08/14/2024 _
Payable to: David Feirin
Amount: $313.60

Reason for Stop Payment: Employee didn‘t receive check.

Lelk Bullis

Authorized Signature ~ Payroll Specialist

Date Stopped = Stopped by

Transaction Number Time Stopped