STAMPED & REDACTED MAHLON CAMPBELL.PDF

Maricopa County
Human Resources

Memo

To: Juanita Garza, Clerk of the Board

Mil

From: Lisa Platek =
Date: June 21, 2022 a

Re: Replacement of Lost Payroll Warrants

st—

PAVERS

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 Lisa P at ext. 63619 for any questions. Please route
approved Affidavits back to County Payroll, Suite 800.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: [EI Duplicate or C1 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.
Mahlon Campbell (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 6/08/2022 (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 him/her in the sum of $769.35 (3)

Signed: Lee——<— (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_2! __day of June 20.22.

VATRMTOT UW EY (x a2

NOTARY PUBLIC

, EILEEN WILLIAMS-PREAS |
My commission expires: > Notary Public - State of Arizona
HQ -dna- ommiselon # 854349 (seal)

Expires November 9, 2022

Warrant/Check Number
(if known) (6) 23 1 37447

Original Date o oe |06/08/2022

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

O For Services or Goods furnished

O Treasurer's refund/payment
C1 Other: j 06/24/2022

Revised April 2015

_ Name Campbell,Mahlon - Confirmed Check’
~“Check# Issue Date : Earnings Taxes Deductions. Net Pay
23137447 06/08/2022 4,236.13 313;37 153.44 769.35
~Regularand Overt me Earnings “Taxes~ — ; -
RegHours: -RegPay OT Hours OT Pay je FED SSDIsMLVEE 16.04
= FED MedicareEE- 17.92).
40.00 4460.00 FED - Withholdng 189.51
* FED SS/Dis ER 76.64)
SoeF BD MedicareER =. 17.92):
- OtherEarnings : eons - Deductions ae € oe
Code ~ Hours Amounts Add to Gross 14-5 After-Tax 2.35°
OTP. (78 gets 42 Before-Tax 151,06
#49 Nontaxable 451.06
eod4. Nontaxable 2.35

ADP Enterprise HR screen print as of: 06/21/2022 09:13 AM

Maricopa County

Human Resoutces

Payroll & Employee
Records Division

DATE: — June 22, 2022
Phone:

Reson Fue TO: _ Eileen Williams/ Lisa Platek
~neee FROM: Lisa Platek
RE: Stop Payment on Warrant

Please place a stop payment on the Warrant listed below. It has been
determined that the Warrant is outstanding as of this date:

Warrant Number: 23137447

Issue Date: 06/08/2022
Payable to: Mahlon Campbell
Amount: $769.35

Reason for Stop Payment: never received

Attach a print screen of the paycheck view.

Authorized Signature — Payroll Specialist

Date stopped /-7- a 2 2-s5pped by LU ZIG lad an

Transaction Number (020262. Stopped fe 2&4.

#32 SmariCompliance’ Updated 02/10/2022

HOME PROCESSES

~ Management & Reversals

Look up the details of a single payment or range of payments by using the form below.
NOTE! The maximum check ranges limiled to 50 checks per request.

DIRECT DEPOSIT SEARCH

* CHECKNU! ER | 23137447 }

LT Range of Check Numbers

AMOUNT STATUS: ALL ~~, Search : Q
Campbell Mahion can # 23137447 Th #xXCOKNX

$769.35 issued on 06/08/2022

StoppedNoid as of 06/22/2022 : : 4