STAMPED & REDACTED JOSEPH DAVID KORNEGAY.PDF

Maricopa County
Human Resources

Memo

To: Juantia Garza, Clerk of the Board

From: Zell Bullis
Date: September 9, 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 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. RECEIVED

SEP 13 2022

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

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 _] 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.

“tenement (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 08/17/2022

(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 $_823-50
Signed: ( Md Pach —— (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 \ day of CEREOEC 20a
C(Mlnzted son,

NOTARY PUBLIC

(3)

COLLEEN M. REDMOND
Notary Public - State of Arizona
MARICOPA COUNTY
Commission # 629162
Expires June 10, 2026

M en ae es:

(seal)
Warrant/Check Number
(if known) (6) 23154910
Original Date of Issue
(if known) (7) 08/17/2022
Reason for original issue of Warrant/Check (8):
Payroll
L_]For Services or Goods furnished S
L_]treasurer’s refund/payment 3
t
L_lother: Pa . ae
Revised April 2015 rE 09/12/2022 1-68
Mm

junta eg

ELE-Elections
Active

- Kornegay, Joseph David
MC1-Maricopa County
2120 - Election Day Services

07/26/2022 Temp/PT

Company:

Pay Group:

MC1
ELE

Period End 08/07/2022

Page’
Line:

2416
5

Off Cycle: N
Separate Check # 0

Reprint: N

Adjustment: N

-Kornegay,Joseph David-MC1/ELE

{ Paycheck View i | 7;
Name Kornegay,Joseph David Confirmed Check
Check# Issue Date Earnings Taxes Deductions Net Pay
23154910 08/17/2022 323.50 323.50
- Regular and Overtime Earnings » ¢ Taxes
Reg Hours Reg Pay OT Hours OT Pay
- OtherEarnings rer Deductions
Code __ Hours Amounts Add to Gross
EPS 14.75 14.75 y,
EPT 23.75 308.75 ¥

ADP Enterprise HR screen print as of: 09/09/2022 02:43 PM