STAMPED & REDACTED DENTAL ASSISTING NATIONAL BOARD INC.PDF
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ie RECEIVED Sie, TO: CLERK OF THE BOARD 0 (nov JUN 28 2021 FROM: Terri Ysaguirre ICOPA COUNTY SUBJECT: Affidavits — Replacement of Lost Warrants RORAD OF SUPERVISORS SIRE DATE: 6/28/2021 Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next available Board agenda Vv The attached item(s) have been researched to ensure that the warrant(s) in question have not been cashed or previously re-issued. Vv The original warrant(s) have had a stop payment done. If you have any questions, please contact Terri Ysaguirre at 602-372-1245 or via e-mail at terri.ysaguirre@maricopa.gov. Approved Affidavits may be routed back to the Superintendent of School Finance Division at 4041 N. Central Avenue #1200, (12th Floor) Thank you. #402 West-MEC Dental Assisting National Board Inc $270.00 Schools Affidavit/Claim Form Application for a Duplicate Warrant/Check (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA (nstruction sheet which is page 2 of this form. Dental Assisting National Board Inc. (1), being first sworn, upon oath deposes and says: Name/Claimant On or about August 4, 2020 (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 ¢2/0 (3) Signed: (Lunt Disthr CEO | (4) (5) Subscribed and sworn to before me this _A“~ day of __ Sewn 20 Al CL. \Lnoese— NOTARY PUBLIC q 4 “OFFICIAL SEAL” ¢ § q VARA A KUENSTER ( | ne a q Notary Public, State Of Illlnols My commission expires: 4 « My Commission Expires October 01, 2023 4 - O a l= A re} 23 Ws RIPE PRID RBRFLRILGY (seal) Commission No. 826025 Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Warrant/Check Number Check 3700342351 Nu Original Date of Issue August 4, 2020 (if. known) (7) _ Reason for original issue of Warrant/Check (8): O) Payroll 06/29/2021 ll For Services or Goods furnished Exam Fees CO Other: Exam Fees S;\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of daim.doc Revised June 2015 A.R.S. 11-632 & 15-999 VECEIVE ber NN) JUN AT 202t || By Dental Assisting National Board, Inc. Measuring Dental Assisting Excellence® June 18, 2021 Board of Directors Western Maricopa Education Center Chair Attn: Christina Pifia Michael Conte, D.M.D., M.P.H. Vice Chair Denise Romero, CDA, COA, Subject: Confirmation of authorized bank signer RDA, Ed.D., FADAA Secretary-Treasurer . Lois Bell, CDA, CPFDA, To whom it may concern, CRFDA, MADAA This letter is to certify that Robert Sautter, DANB’s Chief Financial Officer, is an authorized signer on Dental Assisting National Board’s (DANB) business checking account. Karen L. Comisi, CDA, RDA, FADAA If you have any questions, please feel free to contact me directly. Sandra Garcia, CDA, RDA, FADAA, FAADOM . Kind regards, Steven J. Holm, D.D.S. C Meagan Morton, CDA Constance J. Reed, CDA, Cynthia C. Durley, M.Ed., MBA EFDA, B.S. Executive Director Esther R. Scherb, D.M.D., J.D. Executive Director Cynthia C. Durley, M.Ed., MBA 444 N. Michigan Ave., Suite 900, Chicago, IL 60611-3985 * 1-800-367-3262 * Fax: 312-642-8507 » danbmail@danb.org » www.danb.org