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INTEROFFICE MEMORANDUM Maricopa County Schools Superintendent Office RECEIVED TO: CLERK OF THE BOARD MAY 1 7 2019 FROM: Terri Ysaguirre MARICOFA COUNTY SUBJECT: Affidavits — Replacement of Lost Warrants CLERK BOARD OF SUPERVISORS DATE: 5/15/2019 Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next available Board agenda V The attached item(s) have been researched to ensure that the warrant(s) in question have not been cashed or previously re-issued. V 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.vsaguirre@mcesa.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. #216 Agua Fria Union Elesi Bucumi $55.00 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 MAR1COPA Instruction sheet which is page 2 of this form. ELESI BUCUMI (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 4/16/2019 (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 $ 55.00 •(3) Signed: (4) be/fore / 14. n (5) Subscrlb-e-d- orn o me this / / day of 20 / , 7- NOThRY-POSLIC Iii,, OFFICIAL SEAL : NOEMI CABRALES My commisslop expires: Notary Pubiic - State of Arizona 7g2,3/./ My MARICOPA Comm. Epees Aug. COUNTY 23, 2021 ! j (seal) 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 3700166099 Ake (if known) (6) MAY1y; 2019 Original Date of Issue 4116/2019 DATE,/ • ;02 (If known) (7) IIIIII Reason for original issue of Warrant/Check (8): •••I.rc 'OA ri I I l;:.) • -"A 00 _ u -ERVIS NTY Payroll 0 For Services or Goods furnished CI Other: SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of cialm.doc Revised June 2015 A.R,S. 11-632 & 15-999