STAMPED & REDACTED - FOR AGENDA ATTACHMENT - LINDA BEACOM.PDF

Maricopa County
Human Resources

Viemo

To: Juantia Garza, Clerk of the Board
From: Zell Bullis

Date: May 9, 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 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 4 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form

This application is for: fel Duplicate or [CJ 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.
Linda Beacom (1), being first sworn, upon oath deposes and says:
~Name/Claimant
On or about 03/27/2024 (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 ¢99.47 (3)

Signed: Boendice ad Leto (4)

Note, Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

ri
(5) Subscribed and sworn to before me this L VA 7 Say of AL. Lie a ie A

fll CO. (ous
NOTARY PUBLIC V4

My commission expires:
9-23-2020

inelitedia nhs
ALLAN CHARLES CAMP
Notary Public - Arizona
Maricopa County
Commission # 632763
My Comm, Expires Sep 23, 2026

(seal)

Wi Check Numb
aaa) ©. a 52865024 7 ;

—_—

vara Paes [03/27/2024

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

C1 For Services or Goods furnished
C1 Treasurer's refund/payment 5/10/24
OO Other: :

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice
Revised April 2015

Maricopa County 301 W. Jaffarson St, Suite 800 Pheanix, AZ 35003 602) 5063519

Linda Beacom

Pay Period: End]: ‘Check Date]: Check Number]

jac 2 [Company 2
03/17/2024[ 0327/2024}

Linda Beacom Maricopa County

Hours Warked|

{Current 0.00)

[vYTD 0,00}

Description Dates Hours. Rate Amount YTO Hours YTD Amount} {Oescription Amount YTO!

[Central Board Work03/05/2024 - 03/17/2924 ZT 14.5. 4104.50 Zz 401.50} {State Tax - AZ 2.03 2.03)

Earnings 101.50 101,50} | Employee Taxas. 2.03 2.03)

[Description Amount YTO!

Federal Withholding - Taxable Wages 101.50 101.50)
101.50 101.50}

[State Tax Taxable Wages - AZ

[Marital Status
Allowances
[Additional Withholding: f)

Bank Account Name Account Number USO Amount Amount
Check) 99.47_ USD