STAMPED & REDACTED - FOR AGENDA ATTACHMENT - LUTRECIA SPENCER.PDF

Maricopa County
Human Resources

Viemo

hand detivered
To: Juantia Garza, Clerk of the Board RECEIVED
From: Zell Bullis AUG 13 2024

MARICOPA COUNTY

Date: August 13, 2024 CLERK BOARD OF SUPERVISORS

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 C] 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.
Lutrecia Spencer (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 71312024 (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

warranticheck be issued to him/her.in the sum of $6.00 (3)

signed See P Ace! ae, (4)

Note: esis 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 He day of MAL UST 20. OY
Dinme Mactee Cex

NOTARY PUBLIC DENISE MACKEDA
Public - Arizona
My commission expires: - an

Ol— 10 - JOY 7’ My Comm, Expires 01-10-2028 (seal)

Warrant/Check Number

(if known) (6) 52932879
Original Date of Issue

(if known) (7) 7/3/2024

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

[_]For Services or Goods furnished
(}treasurer’s refund/payment
_lother:

Revised April 2015

Maricopa County 301 W. Jaffar
L Spencer

Lutrecia Spencer [Maricopa County

Pay Petiod'End}
06/23/2024)

(Current
YTD G.ca) 66.00) 0.00 0.00 0.00} 66.00)
Description ” “Dates Hours. Rate Amount YTD Hours YTD Amount}
Central Board Workers 06/16/2024 - 06/23/2024 4 14.5 58.00 4 58,00)
lElection incentive Pay 06/17/2024 - 06/23/2024 4 2 8.00 4 8.001
Eamings 66.00 66.00!
Description Amount YTO!
Federal Withholding - Taxable Wages 66.00 68.00]
[State Tax Taxable Wages - AZ 86.00 66.00
(Maritai Status Single or Married filing separately!
Allowances: O} 0.00%

i) it)
Bank Account Name Account Number USD Amount Amount

(Check) 66.00__ USO}