STAMPED & REDACTED BRAINPOP.PDF

INTEROFFICE MEMORANDUM
Maricopa County Schools Superintendent Office
TO: CLERK OF THE BOARD
FROM: Terri Ysaguirre
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 6/22/2021
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.
#17 Tolleson Elementary BrainPop $175.00
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JUN 25 2021
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MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

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 Instruction sheet which is page 2 of this form.
choi op Ee (1), being first sworn, upon oath deposes and says:
On or about 3/29/2021 (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
175.00
warrant/check be issued to him/her in the sum of $ (3)
schnd- agr—
Signed: (4)
(5) Subscribed and sworn to before me this WU ion day of we, cz 20.2 J.
NOTARY PUBLIC ~—— | \ nna
a : RIED MAN
NOTARY PUBLIC-STATE OF NE mv yORK
My ion expires: No.
comm 02FR6270960
a 24 Qualifiedin (seal)
Westéhenter County
Note. Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Warrant ena. _(3700410739
Original Date or aa 3 /29 /2 021
Reason for original issue of Warrant/Check (8):
O Payroll
For Services or Goods furnished 06/29/2021
~
0 Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S, 11-632 & 15-999

BrainPOP
BrainPOP LLC
Tolleson Elementary School District No. 17
To Whom It May Concern:
The check issued by the State of Arizona, County of Maricopa to BrainPOP LLC on or about 3/29/2019
in the sum of $175.00 was not received by BrainPOP LLC. There is no reasonable probability of the
check being found or presented for payment.
Therefore, BrainPOP LLC requests a replacement check to be issued in the sum of $175.00.
Invoice #: US224927
Your purchase order #: 2210632
BrainPOP LLC
H. Scott Kirkpatrick Jr.
Chief Executive Officer