STAMPED & REDACTED TOINETTE MURPHY.PDF

Maricopa County
Human Resources

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To: Juanita Garza, Clerk of the Board
From: Monica Reyes

Date: April 22, 2022

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 Monica at ext. 68051 for any questions. Please route
approved Affidavits back to County Payroll, Suite 400.

Stale Dated Warrant Duplicate Warrant

Thank you.

Replacement Lost Warrant Form 1 02/25/2015

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Application for a Duplicate or Stale-Dated Warrant/Check

Affidavit/Claim Form

This application is for: Avupiicate or L] Stale-Dated (definitions are on page 2)
C

STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
ony OF MARICOP, A Instruction sheet which is page 2 of this form.

(ounelle
(date}(2) a warrant/check was issued to the

On or about Af ily

above named petson/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.

(1), being first sworn, upon oath deposes and says:

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

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warrant/check be issued to,him/her in the sum of $ | 220 GH .(3)

Signed: Hid (4)

Vv
Note: Pleake attach py of the warrant/check ff available and/or any other
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this 22:27 day of Aprif — 2022-.

NOTARY PUBLIC

KELLI SMITH
Notary Public Arizona

My commission expires:

; Maricopa County
Atre, (3° 2A25 . __ Commission # 808238 (seal)
ff { ly Commission Expires June 13, 20!

~ |-Warrant/Check Number

(if known) (6) 23125185

Original Date of Issue ,
(it known) (7) A | 2 AUZ >
Reasga for original issue of Warrant/Check (8):
pr hay
C) For Services or Goods furnished
04/22/2022
1 Treasurer's refund/payment _ =

© Other:

Revised April 2015 ABS. 11-632 & 11-644

( Paycheck View

Name Murphy, Toinette Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23125185 04/13/2022 1,515.65 126.59 188.09 1,200.97
Reg Hours RegPay  OTHours OT Pay _ FED SSDisMLVEE 93.97
FED MedicareEE 21.98
40.00 741.60 * FED SS/Dis ER 93.97
40.00 741.60 * FED MedicareER 21.98
AZ Withholdng 10.64
r OtherEarnings ~ 7 Deductions —
Code _ Hours | Amounts Add to Gross 14 After-Tax 2.88
AWP 1.75 32.45 Y ; 12 Before-Tax 185.21
* 57 Nontaxable 16.04
* 90ER Nontaxable 0.59
* Q1ER Nontaxable 0.29

ADP Enterprise HR screen print as of: 04/22/2022 11:22 AM