STAMPED & REDACTED - FOR AGENDA ATTACHMENT - THOMAS SOLNIT (3).PDF

Maricopa County
Human Resources

nand deli d
Viemo RECEIVED 4
SEP 05 2024

To: Juantia Garza, Clerk of the Board CLERK BOARD OF SUPER
ERVISORS

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

SRG:

Application for a Duplicate or Stale-Dated Warrant/Check a

Ba a a ;
Affidavit/Claim Form nani uns ‘
This application is for: Duplicate or [] 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.
Thomas Solnit (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 713142024 (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 wz sum of $381.75 (3)
Signed: Gu o (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_2Zncl_day of 24 iagt 2% 2024.

rhe

Notary Public State of Arizona

(Rogge Maricopa County
ei Tami Jo Brooke
Se My Commission Expires 7/18/2026
Commission Number 630515

— (seal)

‘Y Ory
NOTARY PUBLIC

My commission expires
Joly (B, O26 @

Warrant/Check Number

(if known) (6) 52952931

Original Date of Issue _

(if known) (7) 1134/2024

Reason for original issue of Warrant/Check (8):
Payroll
[_IFor Services or Goods furnished. 9/6/24

[Ttreasurer’s refund/payment
(other:

Revised April 2015 ARS, 11-632 & 11-644

Maricopa County 301 W. Jefferson St Suila 800 Phoenix, AZ 85003 +1 (602) SO63519 |

‘Thomas Seinit
arti i : ‘ay Period Begin| Pay: Period End Z e
[Thomas Solnit 07/08/2024) 07/21/2024 07/81 12024]
Current 0.00}
YTD 9,00]
Description Dates Hours Rate Amount YTD Hours YTO Amount!
Central Board Workers 07/08/2024 - 07/21/2024 23.6 14.5 340.75 27.5 398,75)
iGlection Incentive Pay O7/15/2024 - 07/21/2024 20.5 2 41.00 24.5 49.00!
Earnings 361.75, 447,75
‘axable Wages. 5 :
‘Description Amount YTD
‘Federal Withhotding - Taxable Wages 381.75, 447.75)
iState Tax Taxable Wages - AZ 381,75 447.75}
= i ‘ederal|
(Marital Status Single or Married filing separalely
|Allowances i) 0.00%)
ditional Withholding is) 0)
Bank Account Name Account Number USD Amount Amount

381.75 USD)

{Ghack)