041118 STALE DATED WARRANTS 1.PDF

INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office) REQE1VED
MAR I . 5 2018
TO: CLERK OF THE BOARD
MARICORA COUNTY
FROM: Terri Ysaguirre CLERK BOARD OF .SUPERVISORS
tlf6
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 3/13/2018
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 Carolyn Sue Clark $201.69

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.
Carolyn Clark (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about c;,k -93- 17 (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 $ 201.69 .(3)
Signed: /-17C_Ci-el-)f ,IdCc, (4)
(5) Subscribed and sworn to before me this 27 day of February 20 18 .
(5
NOTAR UBLIC BRITTANY CARTER
Notary Public
My commission expires: Maricopa County, AZ
npni act, aoloi My Commission Expires (seal)
April 29, 2019
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 170051697
(if known) (6)
Original Date of Issue 02/23/2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
I*1 Payroll
El For Services or Goods furnished
Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999