STAMPED & REDACTED - FOR AGENDA ATTACHMENT - THOMAS SOLNIT (2).PDF
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Maricopa County Human Resources hand duivered RECEIVED Viemo seb os a MARICOPA GOUNTY GLERK 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 C1 Stale-Dated (definitfons 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 Solnit (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 71312024 (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 — to ya sum of $66.00 (3) Signed: fad 7 (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 and sworn to before me this_Z2nd_day of A og 0 st 20.24. __ Jann Oo Bry NOTARY PUBLIC 4 4 4 4 Notary Public Stete of Arizona Maricopa’ County . Tami Jo Brooke My Commission Expires 7/18/2026 Commission Number 630515 My commission expires: uly 13,2026 (seal) Warrant/Check Number (if known) (6) 52932243 Original Date of Issue (if. known) (7) 7/3/2024 Reason for original issue of Warrant/Check (8): Payroll [_]For Services or Goods furnished [_Ttreasurer’s refund/payment (other: / . s/6/38 Revised April 2015 +4 (602) 5053519 Narne’ ‘earapany® Pay Pariod Gegin[ | Pay Period End]. Chace Date Thomas Soinit [Maricopa County 06/10/2024) 06/23/2024] 07/03/2024] Current 0.00 TD g,00 Hours Rate Amount_YTD Hours YTD Amount} Description Central Board Workers 06/10/2024 - 06/23/2024 4 14.5 58.00 4 58.00 Election Incentive Pay G6/17/2024 - 06/23/2024 4 2 8.00 4 8.00] Eamings 66.00 66.00 ‘Description Amount YTO Federal Withholding - Taxable Wages 66.00 66.00) State Tax Taxable Wages - AZ 66.00 66,00 jarital Status Single or Married fing separately! Allowances it) 0.06% Additional Withholding it) 9) Bank Account Name Account Number USD Amount Amount (Check) 86.00__USO|