STAMPED & REDACTED - VERONIQUE MCCLELLAND.PDF

Memo

Maricopa County
Human Resources

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
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

Thank you.

Replacement Lost Warrant Form

Duplicate Warrant

08/02/2022

Lielng

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.
Veronique McClelland (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 issu it] Met of $65.00 (3)
Signed: 5 J al i (4)

= TVS
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 RTA day ofecember 2023

NOTARY PUBLIC
FR
My commission expires wey a .
ly ission expires:
Feh 23, R26 eipres Pebruany 23 fea)
Warrant/Check Number
(if known) (6) 52486633
Original Date of Issue
(if known) (7) 11/23/2022 : as
Reason for original issue of Warrant/Check (8): i‘ 2
Payroll :
[_IFor Services or Goods furnished
L_]treasurer’s refund/payment
Dlother: | 1/09/2923

Revised April 2015

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

11/23/2022

[Maricopa ‘County

ICurrent 0.00) 65.00 “0.00 0.00) ; 0.00] 65.00]
YTD 0.00 446.50 : 0.00 0.00 446.50

Description ” Dates Hours Rate Amount YTD Hours YTD Amount
\Central Board Workers 13 10/31/2022 - 11/13/2022 5 13 65.00 32.75 425.75)
Hazard Pay 0 20.75 20.75;
Eamings 65.00 446.50:
Description Amount YTO}
Federal Withholding - Taxable Wages 65.00 446.50}
[State Tax Taxable Wages - AZ 65.00 446.50}
Marital Status. Single or Married filing separately|
Allowances Ol 0.00%
[Additional Withholding {) (e)
Payment informatior
Account Name Account Number USD Amount Amount

(Check) 65,00 USD