STAMPED & REDACTED - FOR AGENDA ATTACHMENT - KATHERINE ALEXANDER.PDF

OO ARR May HTY Maricopa County
- Human Resources
2024 JAN-2 PH &: 11

Wond Re tover AR

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: December 28, 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. oD
r\

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 _] State-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.
Katherine Alexander (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 11/22/2023 (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 $ 1200.00 (3)

Signed: Koth— ley. (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 ig va me this AO day of Ldeceube€ 2080.
NOTARY PUBIC
Is ~ BRADLEY BURSTON
My commission expires: aK i) Notary Public » Arizona
"4 Qoall ey Expires 01/08/2024 (seal)
Warrant/Check Number
(if known) (6) 52776294
Original Date of Issue
(if known) (7) 11/22/2023

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

Payroll
(_lFor Services or Goods furnished

[Treasurer's refund/payment 1/03/2024
[_lother: -

Revised April 2015

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

+1 (602) 5063519

Katherine Alexander

| Check Number]

State Tax Taxable Wages - AZ

lame ce Company _ ‘Employee 1D| Pay Period Beginj- _ Pay Period End] _ Check Date!
[Katherine Alexander IMaricopa County 10/30/2023] 11/12/2023} 11/22/2023
ee - Hours Worked] "Gross Pay| Pre Tax Deductions]. Employee Taxes] Post Tax Deductions} = Net Pay!
|Current 0.00 4,200.00) 0.00) 0.00} 0.00) 1,200.00
YTD 0.00) 4,301.00) 0.00 0.00) 0.00) 1,301.00}
Description Dates Hours Rate Amount YTD Hours YTD Amount
[Central Board Workers 14 0 4 56.00}
[Central Board Workers 15 10/30/2023 - 11/12/2023 67.25 15 1,008.75 70.25 1,053.75)
|Central Board Workers 15 OT 10/30/2023 - 11/12/2023 8.5 45 191.25 8.5 191.25}
Eamings 1,200.00 1,301.00
Ee = = _ = TaxableWages_ : 2 s
[Description Amount
[Federal Withholding - Taxable Wages 4,200.00 1,301.00}
4,200.00 1,301.00

E : eo a Z ee ee rederalls
Marital Status Single or Married filing separately
Wlowances {) 0.00%
{e} o}

[Additional Withholding

_ Payment Information:

Bank Account Name

Account Number

USD Amount

Amount

(Check)

4,200.00

USD!

v
MARICOPA
COUNTY

Human Resources
Payroll & Employee Records Division

301 W. Jefferson St., 8th Floor
Phoenix, Arizona 85003

P: 602-506-3519
F: 602-372-8722

Maricopa.gov

DATE: December 28, 2023

TO: Christy Harmon/ Lisa Platek

FROM: = Zell Bullis

RE: Stop Payment on Warrant

Please place a stop payment on the Warrant listed below. It has been determined
that the Warrant is outstanding as of this date:

Warrant Number: 52776294

Issue Date: 11/23/2023
Payable to: Katherine Alexander
Amount: $1,200.00
Reason for Stop Payment: never received

Attach a print screen of the paycheck view.

Authorized Signature — Payroll Specialist

Date Stopped Stopped by

Transaction Number Time Stopped