STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JOSEPH WILSON.PDF

Maricopa County
Human Resources

RECEIVED

Memo whys a

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

To: Juantia Garza, Clerk of the Board
From: Zell Bullis
Date: April 25, 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 1 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: Duplicate 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.
Joseph Wilson (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 312712024 (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 $. 173.95 (3)

Signed: (Aor AN Wa BM? (4)

Note: - stash 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 1a day of Apul 20.0.

(mr Ie. ith ek Os

NOTARY PuphiC CYNTHIA MAYA
Notary Public - Stato of Arizona
My sae expires: MARICOPA COUNTY
LO\tA AOA) expres October 10.2027 | (seal)
Warrant/Check Number
(if known) (6) 52865958
Original Date of Issue
(if known) (7) 3/27/24

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

|For Services or Goods furnished
(_}treasurer’s refund/payment
_lother:

Revised April 2015

Maricopa County 304 W, Jefferson St. Suita 8G0 Phoenix, AZ 85000 +4 (802) 5063519
Joseph Wilson

ay Period Begin}. Pay Period End! ‘Check Datel. Check Number
03/04/2024 03/17/2024) 03/27/2024

Maricopa County
Hours Worked). Gross Pay Employee Taxes}; Post: Tax Deductions|
0,00 773,95] 0,00} 0.00]
0.00 773.95 0.00 0.0)

Hours Rate Amount YTD Hours YTD Amount}

Description

|Central Board Workers 03/04/2024 - 03/17/2024 50 14.5 725.00 50 725,00}
Central Board Workers OT 03/04/2024 - 03/17/2024 2.25 14.5 48.95 2.25 48,95]
Earnings 773.95 773.95

Description Amount YTD}
Federal Withhiciding - Taxable Wages 773.95 773.95)
State Tax Taxable Wages ~ AZ 773,95 773,95]

Marital Status, Single or Married fillng separately

Allowances i) 0.00%
[Additional Withholding 9g 9

re Paymant information: g
iBank Account Name Account Number USD Amount Amount
(Check) 773.95 USD