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REC El V 1 2018 INTEROFFICE MEMORANDUM MARICC.!PA CO_UATY 'CLEAR BOARD—OF SUPER VISORS Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) TO: CLERK OF THE BOARD FROM: Terri Ysaguirre SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 11/16/2018 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 Jesus Betancourt Lopez $46.87 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or El 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. BETANCOURT LOPEZ, JESUS (1), being first sworn, upon oath deposes and says: Name/Craimant On or about 09/06/2018 (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 $46.87 .(3) Signed: 3e-c5 .1iLe?_:\-z-rnc-_,v4 (4) Note: Please attach a copy of the warrant/check if available and/or any other Pvidence that a warrant/check was oriainally issued. orn to befofe me this • (PAL ' Y q 20/a/ OFFICIAL SEAL NOEMI CABRALES Notary Public - State of Alizona My commission expires: MARiCOPA COUNTY ! My Comm. Expires Aug. 23,20211 (seal) Warrant/Check Number 3700080105 (if known) (6) Original Date of Issue 09/04/2018 evED (if known) (7) Reason for original issue of Warrant/Check (8): Payroll 0 For Services Or Goods furnished 0 Treasurer's refund/payment El Other: S:\PROCESSES\Warrants - Duplicate or Stale \02 Forms \Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644