062718 DUPLICATE WARRANTS 2.PDF

RECEIVED
MAY 3 1 Z018
INTEROFFICE MEMORANDUM
MAR ICOPA COUNTY
Maricopa County Education Service Agency (aka CLERK BOARD OF SUPERVISORS
Maricopa County Superintendent of Schools Office) 170
TO: CLERK OF THE BOARD
FROM: Terri Ysaguirre
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 5/31/2018 (#2)
Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next
available Board agenda
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.
#59 Laveen Elementary Jennifer Otis $5,584.45

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.
Jennifer Otis (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about May 24, 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/chp# be issued,tojiimiller in the sum of $5,584.45 43)
Signed: (4)
Notd: Please 'ach a copy of the warrant/check if available and/or any other
eWdence that Warrant/check was originally issued.
(5) Subscribed and sworn to before me this 5./44 day of Miaza... 201 1:
Z4taii 4,i7117iik
NOTARYWUBLIC
My commission expires:
-30-- )9 (seal)
Warrant/Check Number 3700035383
(if known) (6)
Original Date of Issue 5/24/2018 \ AP P--lietrWE-D
if known) (7 I) r
driwir ' firpoTwirr
Reason for original issue of Warrant/Check (8):
Payroll CLERK, BOARD OF SUPERVISORS
MARICOPA COUNTY
0 For Services or Goods furnished
0 Treasurer's refund/payment
111 Other:
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644