STAMPED & REDACTED - DONNA RICE.PDF

Maricopa County
Human Resources

Memo :

To: Juantia Garza, Clerk of the Board

From: Zell Bullis ny
Date: January 5, 2023

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 _] 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.
Donna Rice (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

warrant/check be issued to him/her in the sum of $.323-50 (3)

signe Lance CQ (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 to before me this __ 29" day of HECEMBER>20 LL,

CCswibs Yrowrictr_

NOTARY PUBLIC | en saga SOC
EMILIA KRUPICZER i

issi ires: i = Notary Public - State of Arizona +

My commission expires: MARICOPA COUNTY i

ary ll) 2o2S

i Corn, #563202 Exp. Feb. 11,2023! (seal)

Warrant/Check Number
(if known) (6) 52485011

Original Date of Issue *

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

i i
Reason for original issue of Warrant/Check (8): @ =
= \

[Vv] Payroll eon
LFor Services or Goods furnished__

L_}reasurer’s refund/payment
[_lother: ] 1/09/2923

Revised April 2015

Maricopa County 301 W. Jefferson St. Suite 800 Phoenix, AZ 85003

7a
laricopa County
|Current

YTD. 0.00

0.00!
0.00; 650.50}

Description Dates Hours Rate Amount YTD Hours YTD ‘Amount!
Central Board Workers 13 10/31/2022 - 11/13/2022 23.75 13 308.75 47.75 620.75}
Hazard Pay 11/07/2022 - 14/13/2022 14.75 1 14.75 29.75 29.75)
Eamings 323.50 650.50

Amount YTD}

Description
Federal Withholding - Taxable Wages 323.50 650.50}
State Tax Taxable Wages - AZ 323.50 650.50}
a = edera t
Marital Status Single or Married filing separately!
llowances 0 0.00%!
\dditional Withholding it) i)

Bank Account Name Account Number USD Amount Amount
(Check) 323.50 __ USD