STAMPED & REDACTED - FOR AGENDA ATTACHMENT - LAS RASHID.PDF

Maricopa County
Human Resources

Wand duivercd
Memo RECEIVED 'P
AUG 16 2024
To: Juanita Garza, Clerk of the Board GLERK BOARD OF SUPERVISORS

From: Monica Reyes
Date: August 15, 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 Monica at ext. 68051 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 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/ Claim Form SOun®

This application is for: Gs Duplicate,’ or LJ State-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.

Las aah od (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about i [3K | 24 (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 $ \26% ‘ \8 .(3)
Signed: fot Lote (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) Ta, and we before me this | > day of ISSENS sh 2024.

NOTARY PUBLIC : Shim, WENDY MCINTYRE

f(s Nolary Puhtis - State of Arizona
issi i : ee Commission
My TIA asy Tae Explies January 14, 2028
2 (seal)

Warrant/Check Number SOUS BONUS

(if known) (6)

Original Date of Issue ;
(if known} (7) Wat | 24

Reasgn for original issue of Warrant/Check (8):
Payroll

O For Services or Goods furnished

O Treasurer's refund/payment
a Other: eS

Revised April 2015

8/19/24

[Nante

ompany:.

Check Number

[Las Abdulkarim Rashid

Maricopa County

Gross P Bay
1,760.00 1,269.18
2,673.00 1,960.17

Description Dates Hours Rate Amount YTD Hours YTD Amount} |Description Amount YTD
[Admin Leave With F ce 1.5 33.00) JOASDE 409.12 165.73}
Holiday ta) 8 176.00) [Medicare 25.52 38.76
Regular Pay 07/08/2024 - 07/21/2024 79,75 22 1,754.50 191.75 2,458.50] {Federaj Withholding 109,30 133,38)

‘acation 07/08/2024 - 07/14/2024 0,25 22 5,50 0,25 5,50| [State Tax - AZ 30.93 46.98;
Earnings 1,760.00 2,673.00] | Employee Taxes 274,87 384.85
Description Amount YTD} [Description Amount YTD
IDB - ASRS. 213.31 323.97] [ASRS LTD 2.64 4,01
Pre Tax Deductions 213.31 323.97] | Post Tax Deductions 2.64 4.04

ployer Paid Benefits. e
Description Amount YTO} |Description Amount YTD
IASRS LID 2.64 4.01] JOASDI - Taxable Wages 1,760.00 2,673.00:
IDB - ASRS 213,31 323.97} iMedicare - Taxable Wages 1,760.00 2,673.00)
‘Federal Withholding - Taxable Wages. 1,546.69 2,349.03]
Employer Paid Benefits 215.95 327.98} {State Tax Taxable Wages - AZ 1,546.69 2,349.03}

edéral

Marital Status Single or Married filing Description Accrued Reduced Available

separately| Floating Personal Day 0 0 8
Allowances 0} 4.00%} |Sick - County 3.1 te) 4.741
[Additionat Withholding () ‘acation - County 4.65 0.25 6,82)
S E yment Information
ul Account Name Account Number USD Amount Amount
(Check) 1,269.18 USD;

Chit 2°159.0q 5

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