STAMPED & REDACTED - FOR AGENDA ATTACHMENT - BYRON RHYMES.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

From: Lisa Platek

Date: August 28, 2024

Re: Replacement of Lost Payroll Warrants

20:6 Wd 62 SMV 282

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 Lisa at ext. 63619 for any questions. Please route
approved Affidavits back to County P. i;-Suite.800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 02/25/2015

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

This application is for: (a Duplicate or C] state-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.
Byron Rhymes (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 8/28/2024 (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 $ 1495.77 (3)

Note: a: Pease attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

(5) Sufscribed and sworn Pid me this 28 _ day of fag. ust 20A4

lOUNWNS ne Wo
NOTARY PUBLIC
_. , nAURINDA
My commission expires: waters toe
ray 11, 2027

{if known) (6)

Original Date of I
rigina pat eo a 08/28/2024

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

C1 For Services or Goods furnished

] Treasurer's refund/payment __
O Other:

8/30/24

Revised April 2015

Maricopa County 201 W. Jefferson St. Suite 800 Phoenix, AZ 85003

Byron Rhymes:

+1 (602) 5063519

{Comp Petlod, 2 Pay PenodEnd): :

Byron Rhymes. Maricopa County 08/05/2024 08/18/2024] 08/26/2024) _|

Current 0.00) 2,037.04) 332.64) 2.85) 1,485.77]

{a} 0.00; 36,666.72! 5,987.55 +1,441.52 28,416.65}

z ‘Ernployos Taxes:

Description Dates Hours Rate Amount YTO Hours YTD Amount} |Description Amount YTD!

Excess Life Insuran08/05/2024 - 08/18/2024 oO a 0.418 0 3,24} JOASDI 123.65 2,225.75}

Regular Pay 08/08/2024 - 08/18/2024 0 0 2,037.04 0 36,666.72} |Medicare 28.92 520.54)

Federal Withholding 143.44 2,581.92!

Stata Tax - AZ 36.63 659.34)

Eamings 2,037.22 36,669.96} | Emplayee Taxes 332.64 5,987.55:

Description Amount YTO} (Description YTDI

IDC - ECOCRS 162.96 2,933.29} |EODCRS Disability 54,24)

IEE Cigna HDHP with HSA 31,86 573,48} [Refund Direct Deposit 1,495.76;
IEE Delta Dental 10,35 186.30)
IEE Vision 0.61 10.98)

Pre Tax Deductions 208.78 3,704.04} | Post Tax Deductions 2.85 -1,444.52

‘Taxable Wages? es

Description Amount YTD} |Description Amount YTO)

Basic AD&D - Securian ER 0.38 6,84} |JOASDI - Taxable Wages 1,994.40 35,899.20]

Basic Life - Securlan ER 0.76 13.68] |Medicare - Taxable Wages 1,994.40 35,699.20

(Cigna HOHP with HSA ER 334.13 5,960.34] |Federal Withholding - Taxable Wages 1,831.44 32,965.92

IDB- EORP Legacy EODCRS ER 949.67 23,907.16] |State Tax Taxable Wages - AZ 1,831.44 32,965.92!
IDC - EODCRS 122.22 2,199,96)
IEODCRS Disability 2.85 54,24)
IER Delta Dental 8.34 150.12)
IER Vision 2.53 45,54)
Employer Paid Benefits 4,417.88 32,337.88

Marital Status: Single of Marticd fling separately|
Wlowances: 9 2.00%!
Additional Withholding 9 2)

Payment Informat

Bank

Account Name

Account Number

USD Amount

Amount

Check),

1,495.77,

USD}