STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JEANNE EVANS 52876324.PDF

Maricopa County
Human Resources

Head Oo

To: Juantia Garza, Clerk of the Board 3 eehs
From: Zell Bullis . zs ¢

no <S
Date: October 29, 2024 7 Os
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

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/ Claim Form

This application is for: Duplicate or LI 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.

Jeanne Evans (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 4/10/2024 (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

warrant/check be issued to him/her in the sum of $390.87 (3)
Signed: NANG. {EUAN (4)

Note: lease 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 Vina day of Otol 20 ZY.

NOWARY PUBLIC

TM, JENNIFER ZUBERBUHLER
rem Notary Public - State of Arizona
El (Se MARICOPA COUNTY
7 Commission # 636925
Expires November 17, 2026 (seal)

My commission expires:
Nov. \1, 2

Warrant/Check Number
(if known) (6) 52876324

Original Date of Issue
(if known) (7) 4/10/2024

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

[_]For Services or Goods furnished
[_}treasurer’s refund/payment / 11/01/24
L_Jother:

Revised April 2015 SE :OlKY 82 190 pepe 6

Maricopa Gounty 301 W. Jefferson,

Jeanne Evans

1 (662) 5083519.

Pay Patiod Eng! st

03/31/2024

ore Fax Deductions} I Tax Dedustions
0.00 0.00)
0,09 9,00)

etongs

Dates

YTD Amount

Description Hours Rate Amount YTD Hours
\Cenirat Board Workers 03/18/2024 ~ 03/34/2024 20.75 44.5 300.87 26.75 387.87
Earnings 300.87 387.87

Description

Amount YTO)
Faderal Withholding - Taxable Weges 300.87 387.87
State Tax Taxable Wages - AZ 300.87 387.87

ideal
Marital Status Single or Married filing separately
Allowances 0} 9.00%
Additional Withholding it) Oo
iBank Account Name Account Number USD Amount Amount
(Check) 300.87 USD