110718 DUPLICATE WARRANTS 5

INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office) f,61°
RECEIVED /
OCT 1 5 2018
TO: CLERK OF THE BOARD
MARICOPP, COUNTY
FROM: Terri Ysaguirre CLERK BOARD OF SUPERVISORS
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 10/12/2018
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 Shadowman Sports $3,099.16

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or LI 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.
• 01 0 014fru- ov siotoorbutio, 5 rovers
.JO\\N \-‘,1T c AN (1), being first sworn, upon oath deposes and says:
ame/Claimant
On or about August 21, 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/checkilei issued to him/her in the sum of $ 3,099.16 .0)
(4)
lyr
Note: . ; ttttI a copy of the warrant/check if available and/or any other
evidencetia a vva, --i--ant/check was originally issued.
(5) Subscribed and sworn to before me this day of 20
NOTARY PUBLIC 59 “-ren-iv6
My commission expires:
(seal)
Warrant/Check Number 3700076252
(if known) (6)
Original Date of Issue August 21, 2018
(if known) (7)
CLE 9K BOARD OF SUPERVISORS
Reason for original issue of Warrant/Check (8): MARICOPA COUNTY
0 Payroll
For Services or Goods furnished on August 3, 2018
CI Treasurer's refund/payment
0 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

CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California (-
County of----)1(A
On0( 4 e;r'kt-f 2-f, i g before me, ....i / / A-1 c 21% flt (orn S rA)VA-h R._;)/ piAity(' ,
1
Date Help Insert Name and Title of the Officer
personally appeared -1- V i-{- 1.3 r-PrA U L.- ^(1-- Nr\Art rVI
Name(s) of\Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s),
or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
is true and correct.
WITNESS my hand and official seal.
TIM C. ZARACOTAS Signature
Notary Public - California Signature of Notary Pub
San Francisco County
Commission 2211211
My Comm. Expires Sep 19, 2021
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document/ 1T f)-(- tc•( 1)ULt I3otmpnt Date: - /
Number of Pages: (ri',-vIk Signer(s) Other Than Named Above: /\ C4"
Capacity(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
El Corporate Officer — Title(s): E Corporate Officer — Title(s):
Partner — E Limited E General E Partner — 0 Limited E General
Individual E Attorney in Fact El Individual 0 Attorney in Fact
El Trustee 0 Guardian or Conservator E Trustee E Guardian or Conservator
E Other: Other:
Signer Is Representing: Signer Is Representing:
-er. -e/vel -6, W. -4V 'el 'el .e, -elver -8' e w -exv&r,e-
©2014 National Notary Association • www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907