STAMPED & REDACTED - FOR AGENDA ATTACHMENT -MATTHEW R. LUNN.PDF

Maricopa County
Human Resources

Vemo

To: Juanita Garza, Clerk of the Board
From: Monica Reyes
Date: November 5, 2024

Re: Replacement of Lost Payroil 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 800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 4 02/25/2015

~~ —fipplication fora Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form

This application Is for: Buplicate or J 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.
Matthew R. Lunn (1), being first sworn, upon oath deposes and says:
On or about 10/ 23) 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 penaity 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 ¢ 144.1 6 (3)

signed: reaann | [ J YZ, Y/ 2-029 (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 Se day of —NObator 20. QM.

NOTARY FUBKIC *
oe Ty Public + Stata of
My conjiss n expires: BUS ae Ceonmisoton Baz0ee2
jo. 15. Tit Expires Decambar 15, 2028. (seal)

Warrant/Check Number Ss ZB OO Qu)

(if known) (6) _|
Original Date of Issue
9 (if known) (7) (0 |2a| 2b
Reason for original issue of Warrant/Check (8):
Payroll

O For Services or Goods furnished
O1 Treasurer’s refund/payment
OO Other: ’ 11/5/24

Revised April 2015

Gross Pay] -PteTax Dedtictions

856.27)

0.00

856.27}

0.00

Descripticn Dates Amount YTD Hours YTD Amount] |Description

dmin Leave With F10/07/2024 - 10/13/2024 45 26.21 39.34 1.5 39,31] JOASDI 53.09 53.09)
Floating Personal 010/07/2024 - 10/13/2024 8 26.24 209.68 8 209,68] |Medicare 12.42 42.42
Leave Wilhout Pay 10/07/2024 - 10/13/2024 175 0 0.00 0,00] |Federal Withholding 29.47 23.47
Regular Pay 10/07/2024 - 10/13/2024 22.76 © 26.24 $96.28 22.75 596.28] |State Tax - AZ 17.13 47.13]
Shift Differential Tw10/07/2024 - 10/13/2024 22 05 411.00 22 11.06]
Earnings 856.27 856.27] | Employee Taxes 1412.11 112.44
(Description Amount YTD}
(OASDI - Taxable Wages 856.27 856.27
IMedicare - Taxable Wages 856,27 856.27
Federal Withholding - Taxable Wages 856.27 856.27
State Tax Taxable Wages - AZ 856.27 856.27

Description

Marital Status

separately}
Allowances: 9)
(Additional Withholding )

O.CO%] ISick - County
"| Vacation - County

Floating Personal Day

8 8
1.08 o
1,91 0

aoe

[Bank

Account Namo

Reale
Account Number

USD Amount

Amount

(Check)

744.16 USO!

Cpa S2004GN1\