STAMPED & REDACTED - FOR AGENDA ATTACHMENT - PAULA SMITH.PDF

Maricopa County
Human Resources

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RECEIVED W

NI SEP 05 2024
e m 0) MARICOPA COUNTY

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 | 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.

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

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

warrant/check be issued to him/her in the sum of $275.01 (3)

see Zi ha a, Aw (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 30th day of August 2024.

NOTARY PUBLIC

FRANCES HANSON
ar} A Wolary Public - State of Arizona
My commission expires: MARICOPA COUNTY,
eb nua vy Ay 2020 Expires Februaty 23, 2026 (seal)
Warrant/Check Number
(if known) (6) 52961976
Original Date of Issue
(if known) (7) 8/14/2024
Reason for original issue of Warrant/Check (8):
Payroll
[|For Services or Goods furnished
[Treasurer's refund/payment 9/6/24
(other: i

Revised April 2015

fiom

[PAULA SMITH

2ay Potiad Hagin] = Ray Paved Eng

98/04/2024)

07/22/2024

(Current f ‘5.01
YTD $84 6.06} 275.01

(Description Date: Hours Rate Amount YTD Hours YTD Amount} [Description Amount YTD!
iCentrat Board Work07/23/2024 - 08/04/2024 47.25 14.5 250.12 97.25 250.12] [State Tax - AZ 5.61 5.61
election Incentive PO7/29/2024 - 08/04/2024 15.25 2 30.50 15,25 30.50}

Earnings 280.62 280.62| [Employes Taxes 5.64 5.61

Faxahle Wage

Description Amount YTO!
Federal Withhokiing - Taxable Wages 280.62 280.623
State Tax Taxable Wagas - AZ 280.62 280.623

ts | Status,
llowances

gio or Married filing separately|
9

[Additional Withholding

fi)

Bank

Account Name

Account Number USD Amount

Amount

(Check)

275.01 USD)