STAMPED & REDCATED - FOR AGENDA ATTACHMENT - THELMA COLE.PDF

Maricopa County
Human Resources

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To: Juantia Garza, Clerk of the Board = Qn st
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From: Zell Bullis ~  GNe

Date: August 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 L] 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.
Thelma Cole (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about TN 712024 (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 $ 64:68 (3)

Signed: Phd gea! Gaze (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 _/ zm day of 4 LADS 202-4.
ee el

JULIAN SULEIMAN
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OFAYAOVS My Commission Expires (seal)
Warrant/Check a
(if known) (6) 52942444
Original Date of Issue
(if known) (7) 7/17/2024
Reason for original issue of Warrant/Check (8):
Payroll
[_]For Services or Goods furnished___
LHtreasurer’s refund/payment
LJother: 8/30/24

Revised April 2015

Jefferson St. Suite 800 Phoenix, AZ 6:

Hamar: ee It)  Begin| ‘Pay:Re so: Check Date]
[Thelma Cole 06/24/2024: 07/07/2024 07/17/2024)
Current 0.00) 66.00) 0,90)
\YTO 9.00) 66,90 0.90}

Description Dates Hours. Rate Amount YTD Hours YTD Amount] [Description Amount YTD
Central Board Work06/25/2024 - 07/07/2024 4 14.8 58.00 4 58,00} State Tax - AZ 1.32 1.32
Election Incentive PO7/G 1/2024 - 07/07/2024 4 2 8.00 4 8.00]

Earnings 66.00 66.00] | Employee Taxes 1,32 1.32
(Description Amount YTD}
Federal Withholding - Taxable Wages 66.00 66.00}
State Tax Taxable Wages - AZ 66.00 66.00)
Marital Status Singie or Married filing separately|

Allowances: tt) 9.00%

Additional Withholding Oj

iBank Account Name: Account Number USD Amount Amount
(Check) 64.68 USD)