011619 DUPLICATE WARRANTS 10.PDF

INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office)
FiEi
TO: CLERK CLERK OF THE BOARD 8
FROM: Terri Ysaguirre CLER 'Try
VISORS
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 12/12/2018
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.ysaguirre@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 Deborah Mensah $99.75
DEC '
MARic
CLERK 8Q/:, .1 :','IlSORS

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or U 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.
Deborah Mensah (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/13/2018 (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 $ 99 .75 .(3)
Signed: - 41111IiiP (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 s orn to before me this day of .Y 7 thu 6) . 1.
OFFICIAL SEAL
ANDREA DE LAROSA j
M com ission expi .4* Notary Pubrtc - State of Arizona
MARICOPA COUNTY (seal)
: .F.i.ftit," My Comm. Expires July 17, 2021 !
Warra-nt/ChetIlNumber 3700108794
(if known) (6).
Original Date of Issue 11/13/2018 ED
(if known) (7) (
Reason for original issue of Warrant/Check (8): D1: J11 d10
Payroll VW' . • 1.;sitt/44A
:--i , JPERVISORS
O For Services or Goods furnished MAIIIC.)PA COUNTY
O Treasurer's refund/payment
O Other:
S:\PR0CESSES\warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644