STAMPED & REDACTED - FOR AGENDA ATTACHMENT - MARCEL YAMEOGO.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

AZ: Hd €~ das 1200

From: Zell Bullis
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 1 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: Duplicate or _] stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond fo numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

Marcel Yameogo (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 8/44/2024 (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, er 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 $1282.73 (3)

Signed: ( — — ane) (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_28' day of Pugust 20. AY.

ff a ee
NOTARY PUBLIC’ LEAR WARTY
My commission expires: 3 MARICOPA COUNTY
Duty 24, QOY7 Bopree wy 24 2027 (seal
Warrant/Check Number
(if known) (6) 52963651
Original Date of Issue
(if known) (7) . Be AN2024

Reason for original issue of Warrant/Check (8):
\v] Payroll

L_TFor Services or Goods furnished
[_]treasurer’s refund/payment

Clother: 9/4/24

Revised April 2015

Maricopa

Nat

MARCEL YAMEOGO.

272024)

08/14/2024

NeEPay|

{Current 0,00} 1,402.82) 1,282.73
yto 0,00} 1,807.07] 1,878.89)
|Description Gates Amount YTD Hours YTD Amount} [Description

[Central Board Work07/22/2024 - 08/04/2024 68 14.5 986.00 92.5 1,341.25] jFederal Withholding 92.03 92.031
[Central Board Work07/22/2024 - 08/4/2024 11.75 14.5 255.57 AA7S 255.57] {Stale Tax - AZ 28.06 36.45)
Election Incentive PO7/29/2024 - 08/04/2024 63 2 126.00 87.5 175.00}

incentive Pay OT 07/22/2024 - 08/04/2024 44.75 2 35,25 11.75 35,25]

Earaings 1,402.82 1,807.07] | Employee Taxes 120,09 128,18;

YTD

[Description Amount
[Federal Withholding - Taxable Wages 1,402.82 1,807.07
Slate Tax Taxable Wages - AZ. 1,402.82 1,807.07}

arital Status,

Allowances,

Additional Withholding

Bank

Account Name

Account Number

USD Amount

Amount

(Check)

4,282.73 _ USD)