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RECEIVED NICESA DFc 0 5 2m7 Maricopa County Education Service Agency MARICOPA COUNTY CLERK BOARD OF SUPERVISORS INTEROFFICE MEMORANDUM Maricopa County Education Service Agency TO: Clerk of the Board FROM: CARRIE GUNDERSON SUBJECT: Affidavits — Replacement of Lost /Stale Warrants DATE: 12/4/2017 PLEASE FIND ATTACHED AFFIDAVIT/NOTICE OF CLAIM(S) FOR LOST WARRANTS FOR INCLUSION ON THE NEXT AVAILABLE BOARD AGENDA. A/ The attached item(s) have been researched to ensure that the warrant(s) in question have not been cashed or previously re-issued. The original warrant(s) have had a stop payment done. If you have any questions, please contact Carrie Gunderson at (602) 372-4833 opt.3 or via e- mail at garnishments@mcesa.maricopa.gov . Approved Affidavits may be routed back to the Maricopa County Education Service Agency at 4041 N. Central Avenue #1200, (12 111 Floor) Thank you. Fund 781 Duane Davis 1800030575 Dated 11/21/17 $853.49 4041 N. Central Avenue, Ste. 1200, Phoenix AZ 85012 • Phone 602-506-3866 • Fax 602-506- 3753 www.maricopa.gov/mcesa Twitter: #mcesaaz Facebook: mcesaaz Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: D Duplicate or El 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. DUANE DAVIS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 11/27/17 (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/chec, be issued to him/her in the sum of $ 853 .49 .(3) Signed: (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this 4/ day of Ac.-1,42,e4.- 20 /7 . NOTARY PUBLIC LUZ I. VELASCO Notary Public - State of Arizona My commission expires: My MARICOPA Commission COUNTY Expires C/1. /6 2-02-0 Octobertl, 2020 (seal) Warrant/Check Number 180030575 (if known) (6) Original Date of Issue 11/21/17 APPRC 7fl4. .4 (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll CLERK, BOARD OF SUPERVISORS MAR ICOPA COUNTY El For Services or Goods furnished LI 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