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Maricopa County Human Resources Vemo To: Juantia Garza, Clerk of the Board 9E 3% Hd 6- Udi Pele From: Zell Bullis Date: April 9, 2024 Re: Replacement of Lost Payroll Warranis 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. or Replacement Lost Warrant Form 1 08/02/2022 5 40 Q2VO8. 9 ¥dOSIUEH qT th Praniery pu | Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or LJ 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. Janelle Weaver (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 3/13/24 (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 $ 1030.26 (3) signed: Cowl M Wears (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) Subscribed and sworn ee Va | ~ day of Mace) 20.244. NOTARY PUBLIC WILLIAM GEORGE | Notary Public - Stato of Arizona | | i MARICOPA COUNTY My gommission expires: Commission # 648821 oy a Expires June 10, 2027 Warrant/Check Number (if known) (6) 52854536 Original Date of Issue (if known) (7) 3/13/2024 Reason for original issue of Warrant/Check (8): [Y] Payroll L_TFor Services or Goods furnished L_Itreasurer’s refund/payment _lother: y 4/9/24 Revised April 2015 +1 (602) 5063519 INamo. . \Company: lad Beal “Ray Perlod:end| Janelle Weaver Maricopa Caunty 02/1 pant 03/03/2024] 03/134: 2024] re Tax Deductions) ast Tax Deductians| 1,409.25) 0.00) 0.00 1,030.26 4,109.25) 0.00) 9.00 1,030.26; Description Dates Hours Rate Amount YTD Hours YTD Amount] [Description |Central Board Work02/20/2024 - 03/03/2024 76.5 14.6 1,109.25 76.5 1,109.25] |Federal Withholding 56.80 56.80} [State Tax - AZ 22.19 22.491 Eamings 1,109,25 1,109.25] | Employee Taxes 78.99 78.99: Description Amount YTD) Federal Withholding - Taxable Wages [State Tax Taxable Wages - AZ 1 1 1109.25 4,109.25; 1109.25 4,109.25} ee 0 Federal Marital Status Single or Married filing separately; [Allowances (a) 0.00% [Additional Withholding Ol Bank Account Name Account Number USD Amount Amount (Check) 4,030.26 USD