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INTEROFFICE MEMORANDUM
Ilaricopa County School-Superintendent's Office RECEIVED
TO: CLERK OE DIE 00ARD FEB 02 2018
FROM: lliffie 'Thompson MARICOPA COUNTY
SUBJECT: Affidavits CLERK BOARD OF SUPERVISORS
DATE: 2/2/2018
Pase _find attached 2 AffidavitOotice of CCaim(s)for Cost warrants for incrusion on
the ne4 avada6re Ooard agenda
The attached item(s) have 6een researched to ensure that the warrant(s) in
question have not 6een cashed or previousfy re-issued
The originaCwarrant(s) have had a stop payment done.
you have any questions, please contact Millie Thompson at 372-1244 or via e-mail at
mthompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed 6ack to the
Superintendent of School Finance Division at 4041 X CentrarAvenue #1200, ( 12 th
(Floor) Thankyou.
#216 AcrVA EVA SAMUEL 11(YEW5 $34.72
#216 _AGO ERIA SAWWEL gli(YERS $29.76
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.
Samuel Myers (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/16/2017 (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 $29 .76 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this -22 day of 20_1(d_.
f Cc LacL_ 1/1AC
NOTARY PUBLIC
My commission expires: Notary PAULA Public M. MEDINA —Arizona
- 0/ Maricopa County ("al)
My Comm. Expires Nov 7OI8
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
(If known) (6) /§900d 9 3 7
Original Date of Issue T1/16/2017
(if known) (7)
Reason for original issue of Warrant/Check (8): APPROVED
El Payroll DAT4 FEB 5 20
O For Services or Goods furnished
O Other: CLERK, MARICOPA BOARD OF COI SUPERVISORS INcry
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claindoc
Revised June 2015 A.R.S, 11-632 & 15-999
!n)4
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 MAR1COPA Instruction sheet which is page 2 of this form.
Samuel Myers (1), being first sworn, upon oath deposes and says:
Name/Clalmant
On or about 1 1/30/2017 (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 $ 34 .72 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this 1 2_? day of -c* v\. 20 g.
tt'k vlAe ci
NOTARY PUBLIC ma
PAULA M. MEDINA
My commission expires: Notary Maricopa Public County -Arizona
c5 My Comm. Expires Nov 7, 2018 (seal)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
Arrik.0,..
Warrant/Check Number 180031626
(if known) (6) D FEB 5 2018
Original Date of Issue 11/30/201'7 ,190,
(If known) (7) / A OE or SUPRVC
MARICOPA COUNTY
Reason for original issue of Warrant/Check (8):
Payroll
o For Services or Goods furnished
E=1 Other:
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of cialm.doc ARS. 11-632 & 15-999
Revised June 2015