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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED JAN 1 8 2019 TO: CLERK OF THE BOARD MARICOPA COUNTY FROM: Terri Ysaguirre CLERK BOARD OF SUPERVISORS SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 1/17/2019 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. #65 Littleton Elementary Jason Mierczynski $1,106.92 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 Duplicate or 0 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. ra Name/Claimant 3(,).'i /171/' v L v /7) k-1' (1), being first sworn, upon oath deposes and says: On or about /0 A9 / ciate)(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 bfr-ipsued to her in-th of $ //6 . -„? .(3) Signed: (4) Note: Please attach a copy of the warranVcheck if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this (..) day of ct.rx 20 ct NOTARY PUBLIC • ANAMARIAQUINTANILL A My commission expires: Notary Pulao &Wool Arizona sits ROI:2 Commtasion MARtCOPA COUNTY 845714 Expires May 18, 2022 (seal) ( Warrant/Check Number Of known) (6) Original Date of Issue (if known) (7) / Reatsoh for original issue of Warrant/Check (8): Lk Payroll O For Services or Goods furnished O Treasurer's refund/payment O Other: Revised S:\PROCESSES\Warrants April 2015 - Duplicate or Stale \02 Forms\Warrants Checks notice of claim - Copy.doc A.R.S, 11-632 & 11-644