STAMPED & REDACTED - FOR AGENDA ATTACHMENT - VICKI LYNES.PDF

Maricopa County
Human Resources

RECEIVED
Memo 38 a
MA
CLERK BOARD OF SUP Se soRe
To: Juantia Garza, Clerk of the Board
From: Zell Bullis oe Bs
Date: May 28, 2024 me 2ee
oO pel
Re: Replacement of Lost Payroll Warrants 2 ga
an
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 CJ 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.
Vicki Lynes (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 4/10/2024 (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 $426.30 (3)

Signe

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 _\ day of \ V\ou 209 .
NOTARY PUBLIC _ :
CORDELL WILLIAMS
a . Notary Public ~ State of Arizona
My commission expires: MARICOPA COUNTY
A aad e mmission #600147
GeO" =o Expires March 9, 2025 _ (seal)
Warrant/Check Number ml
(if known) (6) 52875350
Original Date of Issue
(if known) (7) 4/10/2024

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

(_]For Services or Goods furnished
(Treasurer's refund/payment ____
(other:

Revised April 2015

Maricopa Coun son St Suite 800 Phoenix, AZ 88003__ +1 (602) 5083519

Company. Pay Period: Begin}. Pay Period.End Chack Date} Check: Number!
\Vicki Lynes. IMaricopa County 03/18/2024 03/31/2024 04/10/2024)

Kes}. Post ‘Tax Deductions}
8.70) 0.00} 426,30)
16.73 0,00] 525,77)

(Current
YTD

[Description Dates Hours. Rate Amount YTD Hours YTD Amounij {Description Amount YTD)
Central Board Work03/18/2024 - 03/31/2024 3¢ 44.5 435.00, 7 536.50} {State Tax - AZ 8.70 40.73)
Earnings. 435.00 536.50] | Employee Taxes 8.70 10,73
2 ee i Taxable Wages®
[Description Amount yTo
lFederal Withhalding - Taxable Wages 435.00 536.50)
State Tax Taxable Wages - AZ 435,00. 536.50;
Marital Status Single or Married filing separately!
Wowances te) 2,00%|

ditional Withholding 9 f)

+S Payment information é
jaank Account Name Account Number USD Amount Amount
(Check) 426.30__ USD