STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JUDITH SMITH.PDF

Maricopa County
Human Resources

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To: Juantia Garza, Clerk of the Board 2 ome
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From: Zell Bullis oS,

Date: April 18, 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 itern(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

(oF)

Thank you.

Replacement Lost Warrant Form 08/02/2022

Dh parni~p PUCY

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

This application is for: Duplicate or C 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.

Judith Ann Smith (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

—, issued to him/her in the sum of $ 1249.88 (3)
Signed: ‘capli. Lice Lode. (4)

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

(5) yr and sworn to before me this [3 dayof_hy Ay _ 20. 47,

NOTARY PUBLIC —_
A KENNELLY |
Motary Pi -
My commission expires: Hlamcoen ny
€ lex wa Expires August 24, 2027 (seal)
Warrant/Check Number
(if known) (6) 52865507
Original Date of Issue
(ifknown) (7) | —_3eTrea
Reason for original issue of Warrant/Check (8):
LV ]Payroll
L_IFor Services or Goods furnished
[_ltreasurer’s refund/payment
[_lother:
4/19/24
Revised April 2015 ve

Maricopa County 304 W. Jefferson Sl Suita 800 Phoenix, AZ 85003 +1 (602) 5063519

Judith Smith
Luaith Smith Maricopa County 03/04/2024] 03/17/2024 03/27/2024
‘Hours: Worked “ Eimployse Faxes}? Post Tax Dadisctians|
0.00 1,249.88) 9,09) 0,00 1,249.86}
0.00 1,365.38] 0.00) 0,00 1,365.38]

Description j _ Dates Hours Rate Amount YTO Hours _YTD Amount
Central Board Workers 03/04/2024 - 03/17/2024 45 16.5 742.50 52 858,00
(Central Board Workers OT 03/04/2024 - 03/17/2024 20.5 16.5 507.38 20.5, $07.38:
Eemings 1,249.88 1,365.38;
se : ‘axabla: Wages

Description Amount YTD}
Federal Withholding - Taxable Wages 1,249.88 4,385.38

State Tax Taxabie Wages - AZ 1,249.88 1,365.38
s eK Fed State}

Marital Status Single or Married iiling separately|

Allowances, 0 ol

[Additional Withholding ct) Q
Sao po ayment Informatio : oe =
iBank Accaunt Name Account Number USD Amount Amount

(Check) 1,249.88 __ USO}