STAMPED & REDACTED -FOR AGENDA ATTACHMENT - JEANNE EVANS 52865556.PDF
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Maricopa County Human Resources Memo 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 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 3/2712024 (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) signed LV Aang AkLLIZ-— (4) Note. Please attach a copy of the warrant/check if available and/or any other evid that a warrant/check was originally issued. i Subscribed and sworn to before me this _| | !™ day of Ochoa - 2024. \y ri i} Mel NOTARY PUBLIC v JENNIFER ZUBERBUHLER . . ie) Notary Public - State of Arizona My commission expires: MARICOPA COUNTY [ Nov. \1, Lert Expires November 17, 2026 (seal) Warrant/Check Number (if known) (6) 52865556 Original Date of Issue (if known) (7) 3/27/2024 Reason for original issue of Warrant/Check (8): [¥] Payroll [_]For Services or Goods furnished tous [treasurer's refund/payment _lother: \ SE :OHY 82 190 vane Revised April 2015 A.R.S, 11-632 & 11-644 Maricopa County 30% W. Jefferson, 3 Ey Period Endl 03/47/2024: State Tax Taxable Wages - AZ Description Dates Hours Rate Amount YTD Hours YTD Amount} \Centrai Board Workers 03/04/2024 - 03/17/2024 3 44.5 43.50 4 87.00} Eamings. 43,50 87.00 Description Amount YTD Federal Withholding - Taxabie Wages 43.50 87.00) A3.50 87.00 Federal Marital Status. Singie or Married filing separately: Alowances, tt) 9.00% LAdditianal Withholding ) is} Bank Account Name Account Number USD Amount Amount (Check) 43.50 USD)