STAMPED & REDACTED BRENT A. MAHONEY.PDF

Maricopa County
Human Resources

Memo

= 25

To: Cindy Goelz, Clerk of the Board S 2am
From: Zell Bullis y m 25
na «<o
Date: September 9, 2021 ~ poy
Re: Replacement of Lost Payroll Warrants Bi

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, Suite 400.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 04/08/2021

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

This application is for: MZ buplicate or L 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.

Brent A Mahoney (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 99/01/2021 (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

a to him/her in the sum of $1 464.30 (3)
Signed: 7 a (4)

Note Gredé 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 g day of Sept 20.2(.

Caw W Whonr- Ques

NOTARY PUBLIC
My commission expires: EILEEN WILLIAMS-PREAS
\L-A- 2o2z7z Foy rt ga (seal)
Commission # 864340

Warrant/Check Number
(if known) (6) 23077169

Original Date of awe |09/01/2021

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

For Services or Goods furnished
O Treasurer's refund/payment 09/10/2021
O Other: .

Revised April 2015

-Mahoney,Brent A | Company: MC1 Off Cycle: N
MC1 - Maricopa County Pay Group: EXM Separate Check # 0
7944 - West Period End 08/22/2021 Reprint: N
EXM-ExemptEEs / : Adjustment: N
Active 08/09/2021 Reg/FT ; i

Paycheck View

Name Mahoney,Brent A Confirmed Check

“Check# Issue Date Earnings Taxes Deductions Net Pay
23077169 : 09/01/2021 1,848.00 154.36 229.34 1,464.30

- Regularand Overtime Earnings - Taxes
RegHours RegPay OTHours © OT Pay | FED SSDisMLVEE
: | FED MedicareEE

40.00 924.00 * FED SS/Dis ER
40.00 : 924.00 P| * FED MedicareER
AZ Withholdng

_ OtherEarnings: — + t= (Deductions
_ Code _ Hours Amounts Add to Gross} 14 After-Tax

12 Before-Tax
* 12 Nontaxable
ped Nontaxable

ADP Enterprise HR screen print as of: 09/09/2021 09:31 AM