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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED MAR 1 9 2018 TO: CLERK OF THE BOARD MARICOPA COUNTY FROM: Terri Ysaguirre CLERK BOARD OF 3UPERVISORS SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 3/16/2018 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 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. #214 Tolleson Union Medical Expense Reimbursement Trust $9,283.88 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. Medical Expense Reimbursement Trust .(1), being first sworn, upon oath deposes and says: Name/Claimant On or about November 22, 2017 (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 $ 9,283 -88 .(3) Signed: (5) Subscribed ad sworn to before me this NOTARY PUBLIC ELAINE GOETZE Way Pubia - State of Af17.008 My commission expires: My MARICOPA Commission COUNTY Expires .'`%/r7(c90)°( Mardi 27, 20i9 (seal) 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 480046065/214743903 (if known) (6) Original Date of Issue 11/22/17 (if known) (7) n . .r 1- , 20 2018 Reason for original issue of Warrant/Check (8): IN Payroll 0 For Services or Goods furnished CLERK, MARLCO' BOARD OF SUPERVISORS 1 NT'? 0 Other: SAPROCESSES\Warrants - Duplicate or Stale\02 Fornns\Schools\Schools-Warrants Checks notice of claim.doc Revised June 2015 A.R.S. 11-63213(15-999