STAMPED & REDACTED - ROCHELLE PERRY.PDF

Maricopa County
Human Resources

Memo cb WAND DIE Were

To: Juantia Garza, Clerk of the Board DEC 8 8 202
C26 202?
MARICGPA COUNTY
From: Zell Bullis GLERK BOARD OF SUPERVISORS
Date: December 28, 2022
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.
Oo

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 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.

Rochelle Perry (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 11/23/2022 (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

se, fecha issued to ee, in the sum of $396.50 (3)
(Bug — (4)

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

Signed:

(5) Subscribed and oI me this Lz a day ot facet 202-_.

OXHBLE OWARDAWHDLS--O
Notary Public, State of Arizona
Maricopa County
Commission # 601538
My Commission Expires

My commission expires: : April 03, 2025
(seal)

NOTARY PUBLIC”

Warrant/Check Number

(if known) (6) 52485643
Original Date of Issue

(if known) (7) 11/23/2022

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

CO For Services or Goods furnished

L_]treasurer’s refund/payment 12/28/2022
Llother: =

Revised April 2015

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003 +1 (602) 5063519

Rochelle Perry

Name |\Company Employee wy © Pay Period Begin Pay Period End} Check Date{ Check Number}
[Rochelle Perry Maricopa County i 10/34/2022! 11/43/2022 11/23/2022

Hours Worked) Gross Pay| Pre Tax Deductions; Employee Taxes| Post Tax Deductions| Net Pay}
|Current 0.00; 396.50 0,00) 0.00) 0.00) 396.50!
YTD 0.00 681.00 0.00 0.00; 0.00) 681.00]

Eamings
Description Dates Hours Rate Amount YTD Hours YTD Amount
|Central Board Workers 13 10/31/2022 - 11/13/2022 28.75 13 373.75 49.5 643.50}
|Hazard Pay 11/07/2022 - 11/13/2022 22.75 4 22.75 37.5 37.50)
Eamings 396.50 681.00
Taxable Wages.
[Description Amount YTD|
Federal Withholding - Taxable Wages 396.50 681.00}
State Tax Taxable Wages - AZ 396.50 681.00}
Federal} State}
Marital Status Single or Married filing separately|
Allowances. | 0.00%,
Additional Withholding it) 0
Payment Information S

Bank Account Name Account Number USD Amount Amount
(Check) 396.50 __ USD}