STAMPED & REDACTED - FOR AGENDA ATTACHMENT - DIMITRA BUNDY.PDF

Maricopa County
Human Resources

Viemo

To: Juanita Garza, Clerk of the Board
From: Tammy O'Keefe
Date: November 20, 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 Tammy at ext. 67647 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

Stale Dated Warrant Duplicate Warrant Bz

Thank you. 3 $g%ss
€
&

Replacement Lost Warrant Form 1 02/25/2015 ER

Application for a Duplicate or Stale-Dated Warrant/ Check

Affidavit/Claim Form

This application is for: Duplicate or C1 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.
Dimitra Bundy (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 11/08/2023 (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 vear 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

ee ae issued to hi ier in the sum of $1 352.20 (3)

oul cL (4)

Note. Please ene a2 copy~of the warrarkioheck if available and/or any other
evidence that a warrant/check was originally issued.

Signed:

(5) Subscribed and sworn to before me this 174 day of NMovern bev 20 ¥3.

NOTARY PUBLIC // O [
WEIEZ ssion expires: 1a

Notary Public - State of Arizona

MARICOPA COUNTY
#599577
eee Maen 4 2028 | (seal)

GLADYS SANCHEZ ]

aot Number
(if known) (6) SRTCHBIR

Original Date ormsue 11/08/2023

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

0 For Services or Goods furnished
1 Treasurer’s refund/payment / me 21/2023
OO Other:

Revised April 2015 Min. ba-use Wak UT

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

[compar

[Dimitra Long Bundy

iMaricopa County

+1 (602) 5063519

‘Check Datel

11/08/2023}

|Current

1,888.75|

1,352.20}

[YTD

1,888.75

1,352.20)

=

[Description Dates Hours Rate Amount YTD Hours YTD Amount] |Description Amount YTD}
Overtime Time One 10/23/2023 - 10/29/2023 0.5 11.695 17.55 0.5 17.55} |OASDI 117.10 117.10
[Regular Pay 10/46/2023 - 10/29/2023 80 23.39 1,871.20 80 41,871.20] |Medicare 27.39 27.39}

|Federal Withholding 126.75 126.75

[State Tax - AZ 33.19 33.19)
Eamings 1,888.75 1,888.75} | Employee Taxes 304,43 304.43
[Description Amount YTD [Description Amount YTD)
IDB - ASRS. 229.29 229.29} JASRS LTD 2.83 2.83
Pre Tax Deductions 229.29 229,29] | Post Tax Deductions 2.83 2.83

Amount

Description Amount Description

IASRS LTD 2.83 2.83} [OASDI - Taxable Wages 1,888.75 1,888.75

|OB - ASRS 229.29 229,29} |Medicare - Taxable Wages 1,888.75 1,888.75
iFederal Withholding - Taxable Wages 1,659.46 1,659.46]

Employer Paid Benefits 232.12 232.12] |State Tax Taxable Wages - AZ 1,659.46 1,659.46

Marital Status Single or Married filing] Description Accried Reduced _ Available

separately Sick - County 2.68 0 2.68|
Allowances 0} 3.00%} |Vacation - County 0 0 86]
[Additional Withholding 0}

Bank

Account Name

Account Number

USD Amount

Amount

(Check)

4,352.20 USD)