STAMPED & REDACTED - FOR AGENDA ATTACHMENT - CARROLL CHAPMAN.PDF
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Maricopa County Human Resources Memo To: Juantia Garza, Clerk of the Board From: Zell Bullis Date: July 23, 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 cali 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 h ne de VE i 08/02/2022 Bee JUL 28 2024 MARICOPA COUNTY GLERIK BOARD OF SUPERVISORS Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/ Claim Form This application is for: Duplicate or [_] 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. Carroll Chapman (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 4110/2024 (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 $937.48 (3) Signed: Cat? Bela Appr (4) Note. Please attach A copy of the warrantfcheck if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this 5th day of Jul 20. 24} . J ach Yt einpane NOTARY PUBLIC RACHEL LANGRINE inant + Notary Public - Arizona My commission, expires: ©) ae 01 'sior O ! oO 8 02d. S “my Comm, Expires Jan 8, 2028 (seal) Warrant/Check Number (if. known) (6) 52875337 Original Date of Issue (if. known) (7) 4110/2024 Reason for original issue of Warrant/Check (8): Payroll L_IFor Services or Goods furnished (_}treasurer’s refund/payment [_lother: Revised April 2015 | | | | se . Carroll Chapman | 03/31/2024] 04/10/2024! (Carroll Chapman |Maricopa County Begin 03/18/2024] ost.Tax Dedustions| :NetP 9.00 337.48) Description Dates: Hours Rate Amount. YTO Hours YTD Amount} |Description Amount YTD (Centrat Board Work03/18/2024 - 03/31/2024 23.75, 14.5 344.37 26.75 387.87} |State Tax - AZ 8.89 7.76) Eamings 344.97 387,87] | Employee Taxes 6.89 7.76 Description Amount YTD Federal Withhelding - Taxable Wages 344.37 387.87 Slate Tax Taxable Wages - AZ 344.37 387.87, j Eederal Marital Status. Single or Marie filing separately Allowances i) 0.00% Additional Withholding QI iBank Account Name Account Number USO Amount Amount (Check) 337.48 USD]