STAMPED & REDACTED - FOR AGENDA ATTACHMENT - SYLVIA DE LEON-MARQUEZ.PDF

Maricopa County
Human Resources

Vemo

TO: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: August 8, 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.

S138 Wd 8- any yene

pec Lost Warrant Form 1 08/02/2022

NOS VdOolN VEY
FF? S405! IAUBdNS 40 GAY
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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.
Sylvia De Leon-Marquez (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 71712024 (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 $49-50__. (3)

signee:(Sihe_KOt Toon = Lahfll de (4)

Note; Please attach a copy of the vis ot cet if available and/or any other
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this__|__day of Podqust 202+ .
aoncep horrencles_
NOTARY PUBLIC

MARICOPA COUNTY

t

My commission expires:
A Commission # 607240 !

!

(seal)

Warrant/Check Number
(if known) (6) 52942489

Original Date of Issue
(if known) (7) 711712024

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

|_]For Services or Goods furnished.
L_]tTreasurer’s refund/payment

[_lother: 8/09/24

Revised April 2015

Maricopa County 401 W. Jefferson St. Suite 800 Phoenix, AZ 85003 +1 (602) $063619
Sylvia De Leon-Mar

Vy Pedod End AEC

06/24/2024] 07/07/2024 07/17/2024)

Syivia De Leon-Marquez jaricopa County

SEE Tans Work Pout Tex Deduciane iB
(Current 0.00) 49,50} 0,00) 49,50)
YTD 0.00) 115.50} 0.00 115.50}

‘Description 7 Dates Hours Rate Amount YTD Hours YTD Amount
\Central Board Workers: 06/24/2024 - 07/07/2024 3 14.5 43.50 7 107.50)
Election Incentive Pay 07/01/2024 - 07/07/2024 3 2 6.00 Z 14.00)
Eamings 49.50 115.50

IDescription
Federal Withholding - Taxable Wages 49,50 475.50]
State Tax Taxable Wages - AZ 49,50 115.50

Marital Status, Single. or Married filing separately
Allowances 9
Additional Withholcing it) fy)

iBank Account Name Account Number USO Amount Amount
(Check) 49.50 USO!