STAMPED & REDACTED - FOR AGENDA ATTACHMENT - HARRY BOETTCHER.PDF

Viemo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis

Date:
Re:

May 9, 2024

Replacement of Lost Payroll Warrants

Maricopa County
Human Resources

agi Ka 6- HARE

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

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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.
Harry Boettcher (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 jgsued to himyher jn the sim OF $ 300.87 (3)

Signed: Ala CAAT A EE. Lith (4)

Note: bease 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_ £6 day of _A“/7é 2027,

SS
oe

NOTARY PUBLIC ndltanl PoelcitBr
LAZARC FERNANDEZ
G Notary Public - Arizona
My commission expires: } BH), Haricapa County
té, ZE ZoZ7 f My Comm. Expires Dec 28, 2027 By (seal)
Warrant/Check Number
(if known) (6) 52875405
Original Date of Issue :
(if known) (7) 4/10/2024

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

O For Services or Goods furnished

[Ttreasurer’s refund/payment
(_Jother:

5/10/24

Revised April 2015 : ~

RRA LON Be

i ess
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Maricopa County 301 W. Jefferson St Suite 809 Shoonix AZ 85003

Harry Boettcher

Pay Period Begin’

+1 (602) 5083519

‘Check Date|.Check Number}

Eamings

Harry Boettcher iMaricopa Caunty 03/48/2024) 03/31/2024) 04/40/2024)
‘Hours Worked! ré Tax: Deductionis| = Post Tax Deductions) i= Net Pay
(Current 9.00 Oe) 0,00) 300,87]
[YTD 0.00) 0.00) 0.09) 344.37
Description Dates Hours Rale Amount YTD Hours YTD Amount]
Central Board Workers 03/18/2024 - 03/31/2024 20,75 14.5 300.87 23.75. 344.37)
300.87 344.37)

‘Taxable Wages:
IDescription Amount YTO}
|Federal Withholding - Texable Wages 300.87 344.37]
‘State Tax Taxable Wages - AZ 300.87 344.37]

‘ederal
larital Status. Single ar Marriod filing separately!
Allowances iu 9.00%)
Additional Withholding a 0)
z Payment Information:
Bank Account Name Account Number USD Amount Amount
(Check) 300.87 _ USD]