STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JEANNE EVANS 52854654.PDF

Maricopa County
Human Resources

Viemo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: October 29, 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 4 08/02/2022

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

This application is for: Duplicate or C 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 3/13/2024 (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 $.43-50 (3)

signe: A wre (0214 “

note mease 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 _| | * day of Octo _ 20.2.

lid Dd

NOTARY PUBLIC
+ ae a Not -
My commission expires: =e MARCO ons
sv WD, WU Ve” Expires November 17, 2026 (seal)
Warrant/Check Number
(if known) (6) 52854654
Original Date of Issue
(if known) (7) 3/13/2024
Reason for original issue of Warrant/Check (8):
[¥] Payroll
For Services or Goods furnished —
L_]treasurer’s refund/payment : ~
L_lother:

Revised April 2015 BE :O1HY 82 190 pene ALRS, 11-632 & 11-644

ering Beglat
02/19/2024

(Description Rate Amount_ YTD Hours YTD Amount
(Central Board Workers 02/19/2024 - 03/03/2024 3 14.5 43.50 3 43.501
Eamings 43.50 43.50
[Description Amount YTD)
[Federal Withholding - Taxable Wages 43,50 43,50!
[State Tax Taxable Wages - AZ 43.50 43.50}
Marital Status Single or Martted filing separately|

Allowances: i] 0.00%!

(Additional Withholding ) |

[Bank Account Name Account Number USD Amount Amount

(Chack} 43.50 USD}