STAMPED & REDACTED - FOR AGENDA ATTACHMENT - JULIE RUDNICK (2).PDF

Maricopa County
Human Resources

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RECEIVED '2

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MARICOPA GOUNTY
CLERK BOARD OF SUPERVISORS

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: September 5, 2024

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 L] 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.
Julie Rudnick j '
—NamaCainant (1), being first sworn, upon oath deposes and says:
On or about 713112024 (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

(3)

(4)

evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this “4 Oth day of Avg iit= 20 04:

Fromees | onsend

NOTARY PUBLIC
; WERANGES HANSON
commission expires: OOARICOPAGOUNTY
Ee bruawy 23,202 espe Febuary 2800)

Warrant/Check Number

(if known) (6) 52952987
Original Date of Issue

(if known) (7) 7/31/2024

Reason for original issue of Warrant/Check (8):
[Y] Payroll
L_IFor Services or Goods furnished
9/6/24
[_Ttreasurer’s refund/payment : a Vor

CL Other:

Revised April 2015 A.R.S, 11-032 & 11-044

2-4 (602) 5063519

Nulio Rudnick [Maricopa County 07/08/2024) 07/34/2024
Current 9.00 0.00} 49.50}
\YTO 0.00) 9.00 49.50
Description Dates Hours Rate Amount YTD Kours YTD Amount!
Gentral Board Workers: 07/08/2024 - 07/21/2024 3 14.5 43.50 3 43.501
Election Incentive Pay 0711512024 ~ 07/21/2024 3 2 6.00 3 6.00}
Earnings 49.50 49.50
‘axable Wages’ =
Description Amount YTO!
Faderal Withholding - Taxable Wages 49.50 49.50}
State Tax Taxable Wages - AZ 49.50 49.50)

Maritai Status Single or Married filing separately!
Allowances 0} 2.00%
Additional Withholding i} Ol

Payment Information: ’:
Bank Account Name. Account Number USD Amount Amount
(Check) 49.50 USD}