STAMPED & REDACTED - PAMELA BUITIMEA.PDF
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Maricopa County Human Resources Memo To: Juantia Garza, Clerk of the Board From: Zell Bullis Date: January 5, 2023 MM Ly / Ve 3 Re: Replacement of Lost Payroll Warrants Chee 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. Pamela Buitimea (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 Check be issued to him/her in the sum of $ 341-50 (3) (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Sign (5) Subscribed and sworn to before me this uch day of Janve@ py 2023. Panamera Homa? NOTARY PUBLIC My commission expires: Feb a3 Joab Warrant/Check Number (if known) (6) 52487233 Original Date of Issue _ <3 (if known) (7) 11/23/2022 2: 3 Reason for original issue of Warrant/Check (8): . BS Payroll ; L L_]For Services or Goods furnished___ m > L_]Treasurer’s refund/payment L_lother: 1/09/2023 Revised April 2015 Maricopa County 301 W. Jefferson St, Suite 800 Phoenix, AZ 85003 Pay Period Bagin (ae Pay Period Endy 10/31/2022 11/13/2022 0.00) 0.00) State Tax Taxable Wages - AZ peer CNRS es y IDescription Amount YTD Hours YTO Amount Bilingual/Premium Training 11/07/2022 - 11/13/2022 1 25 25.00 2 50.00 \Central Board Workers 14 40/31/2022 - 11/13/2022 215 14 301,00 38.5 539.00 Hazard Pay 11/07/2022 - 11/13/2022 15.5 1 15.50 30.5 30.50 Earnings 341.50 619.50. (Description Amount YTD: Federal Withholding - Taxable Wages 341.50 619.50! 341.50 619.50} [(Check) Marita! Status, Single or Married filing separately| ‘Allowances it) 0,00%| ‘Additional Withholding 9 it] Account Name Account Number USO Amount Amount 341.50 USD}