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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED TO: CLERK OF THE BOARD OCT 1 9 2018 FROM: Terri Ysaguirre MARICOPA COUNTY SUBJECT: Affidavits — Replacement of Lost Warrants CLERK BOARD OF SUPERVISORS DATE: 10/17/2018 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 terrLysaguirre@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. #79 Litchfield Elementary Soliant Health $4,070.25 EIVE NOV 0 8 2018 M.' - `XY.JA CLERK RD OF 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. Soliant Health (1), being first sworn, upon oath deposes and says: Name/Glaimanl On or about August 14, 2018 (clate)(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 t 4,070.25 .(3) Signed: (4) (5) Subscribed and sworn to before me this _ day of 004421/20 NOTARY PUBLIC 4014:I.:::set, BARBARA LEE GONZALEZ My coRnission /expires: * MY COMMISSION # FF933551 1 (`) EXPIRES: August 11, 2019 (seal) OF A. Bonded Thru Budget Notary Services 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 3700072528/79722629 (if known) c_§1 Original Date of Issue 08/14/18 (if known) (7) APPB; 1 Reason for original issue of Warrant/Check (8): fl Payroll Fy. For Services or Goods furnished CLERK, MAR1COPA BOARD OF COUNTY SUPERVISORS 1==1 Other: SAPROCESSES\Warrants - Duplicate or Stale \02 Forms\Schools\Schools-Warrants Checks notice of daim.doc Revised June 2015 A.R.S. 11-632 & 15-999