STAMPED & REDACTED - FOR AGENDA ATTACHMENT - PATRICIA MARTIN.PDF

Maricopa County
Human Resources

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RECEIVED ‘€

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CLERK BOARD OF SUPERVISORS

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: September 5, 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/Ciaim Form

This application is for: Duplicate or CJ 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.
eee Martin (1), being first sworn, upon oath deposes and says:
jame/Cjaiman
On or about 8/14/2024 (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

warta’ eck Ye issued to him/her in the sum of $289.12 (3)
Signed: Ln tay, ra— (4)

c
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 2H day of Auger 202¥%.

Sa—:

NOTARY PUBLIC
(<Giim, SHAVONE BROOKS
My commission expires: ease Notary Fut BUNTY
Mey IVE Zor BSF commission # 629083 (seal)
a rea May 47, 2028

Warrant/Check Number

(if known) (6) 52962167

Original Date of Issue

(if known) (7) 8/4/2024 - |

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

|For Services or Goods furnished
CI Treasurer's refund/payment
CJ Other:

9/6/24

Revised April 2015

08/04/2024) 08/44/2026

Employen Tavs]
0.00)
0.00; 6.00 289.12

(Narn
Patricia Martin Maricopa County

lours: Worked
Current 9,00)
YTD 9.00)

Description Amount. YTD Heurs YTD Amount
Bifingual/Premium Training 07/29/2024 - 08/04/2024 1 25 25.00 1 25.00
\Central Board Workers 07/23/2026 - 08/04/2024 16.25 14.5 235.62 16.25 238.62}
Efection Incentive Pay 07/29/2024 - 08/04/2024 14.25, 2 28.50 44.25 28.50
Earnings 289.12 289.12!
ascription Amount YTO}
(Federal Withholding - Taxable Wages 289.12 289.12
(State Tax Taxable Wages - AZ 289.12 289.12
Z : pee ae pncccsaaeanae State]
Marital Slatus Single’
llowances ) 0.00%
[Additional Withholding bY} 9)

Account Name Amount
(Check). 289.12 USD}