STAMPED & REDACTED - FOR AGENDA ATTACHMENT - THOMAS SOLNIT (1).PDF

Maricopa County
Human Resources

hand oUlivered
RECEIVED

Viemo SEP 05 2024

MARICOPA COUNTY
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 4 08/02/2022

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/ Claim Form

This application is for: Duplicate or [_] 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.

Thomas Soinit (1), being first sworn, upon oath deposes and says:
Name/Craimant

On or about 8114/2024 (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 ya of $1424.88 (3)
Signed: o A - (4)

Pipi 7
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 22.10 cd_day of Aug pot 20.2.4.

NOTARY PUBLIC jo

4

2 38, Maricopa County

Tami Jo Brooke 4
My Commission Expires 7/16/2026  <

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qs

My commission expires: Commission Number 639515 . &
Dolby 13, 2026 (seal)
Warrant/Check Number
(if known) (6) 52062402 a
Original Date of Issue
(if known) (7) 8/4/2024

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

[Vv] Payroll
(For Services or Goods furnished
[_Hreasurer’s refund/payment

[_lother: 9/6/24

Revised April 2015 4

Maricopa County 304 W. Jeti
Thomas Solni

jaricaps County

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+ 2) 5083519

07/22/2024)

08/04/2024) 08/14/2024)

Grass Pay! Kes} Post-Tax Deductions}
1,686.00; 9.00} 1,424.88)
2,027.75; 0,00} 4,872.83

Description Dates Amount YTD Hours ¥TO Amount} Description Amount ¥TO}
Central Board Work07/22/2024 - 08/04/2024 64.5 14.5 935.25 92 1,334.00} JOASDI 125.72 425.72
ICentral Board Work07/22/2024 - 08/04/2024 2 145 456.75 2 458.75] |Medicare 29.40 29.40)
IFlection Incentive PO7/29/2024 - 08/04/2024 62.5 2 125.00 87 174.00]
incentive Pay OT 07/22/2024 - cavo4/2024 21 2 63.00 24 63.00
[Earnings 1,580.00 2,027.75] [Employee Taxes 155.12 185.12

Description

Amount Aaie)

IOASDI - Taxable Wages
IMedicare - Taxable Wages

State Tax Taxable Wages - AZ

Federal Withholding - Taxable Wages

2,027.75 2,027.75
2,027.75 2,027.75
1,580.00 2,027.75}
4,680.00 2,027.75

Federal}:

Marital Status

llowances

Single or Married filing separately!
it)

[Additional Withholding,

is)

entt Informatio

Bank

Account Name

Account Number

USB Amount

Amount

(Check)

1,424.86 USO}