STAMPED & REDACTED - RONALD GUZICKI.PDF

ofa5 JAY -B PH 2 3G

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: January 8, 2025

Rex 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 Ql Stale-Dated {definitions are on page 2)

STATE OF ARIZONA - | Nate: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.

Ronaid Guzieki (1), being first sworn, upon oath deposes and says:
NameGlaimant

On or about . 44/20/2024 {date)(2) a warrant/check was issued to the

above named persan/entity In the amount as stated belaw. Such warrant/check was
either never recelved or was subsequently inadvertently last or destroyed and there Is
no reasonable probability of its being found or presented for payment, ar 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, ws er in a of $1462.04 (3)
Signed: ahh im : (4)

Note. Please altach a copy of the warrant/check If available and/or any other
evidence that a warrani/check was originally issued.

(5) Subscribed and sworn to before me this_[7 day of December __ 2024_.

My commission expires:
wpe) srt

Warrant/Check Number

Gt known) (6) 53092102

Original Date of Issue

41/20/2024

_ Gf known) (7)
Reason for original issue of Warranit/Check (8):
Payroll
(|For Services or Goods furnished
[_Trreasurer’s refund/payment __ —_

(lother: _ : —
} 1/09/25

Reviged Aptil 2015 & L644

Maricopa Count

Check Datel “Check Nuinbey

fRonald Guzish

iiaricopa County

1Hit0/2024

(120720251 |

Current 0.00 4,884.12 0.00] 121.18 0.09] 1482.94
iw 0.60 5499.49) 0.00 408.48 0.09] 4,930.97
Descrplon Oates Hous Rate mount] Descioton

Central Board Warki0728/2024. 1140/2024 «= «6475 4.S i807 258.75 3,766.36} A801 331.04
Hentrat Board Work 10/28/2024 « 11/10/2024 uw 14s 436,75 50.78 1,103.62} Madicare THAR
Election Incenbve PH2024- 11102024 62.75 2 128.80 in5 360.00

incentive Pay OT 1012672024 » 11/10/2024 2 2 63.00 39.75 119.25}

Earnings (584.12 $339.43} [Employee Taxes 121,18 400.46)

Oescription Amount YTD
IOASOI - Taxabie Wages 4,584.12 $339.43}
Medicare - Taxable Wages 4,584.12 §,339.43
Federal Withholding - Taxable Wages 1,584.12 5,339.43
State Tax Taxable Wages - AZ 1,584.12 $339.43

atital Status

Sinule or Married fing separately]

[Allowances d 0.00%)
LAdeitional Withholding . il i)

Bank

Account Name

ett oe

USO Amount

Amount

Check)

1,462.94 USD)