011718 DUPLICATE WARRANTS 12.PDF

RECEIVED
DEC 182017
INTEROFFICE MEMORANDUM MARICOPA COUNTY
CLEBILB LIPERVISORS
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office)
TO: CLERK OF THE BOARD
FROM: Terri Ysaguirre
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 12/15/2017
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 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.
#214 Tolleson Union Gateway Chevrolet #480033942 $356.41

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.
Gateway Chevrolet (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about October 12, 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 $ 356.41 .(3)
Signed: /U Arkt (4)
'5)\Subscribed nd sworn to before me this LI2 day of _____________ 20 F.) .
NE ARY P T IC CAROL OFFICIAL L. HOOVER S
NOTARY MARICOPA PUBLIC COUNTY - ARIZONA
Mv commission expires: th' Comm. Expii•es May 22.2020
, ilbictij 22 207( (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 480033942/214742830
(if known) (6) A 12 p R 0 v E i
Original Date of Issue 10/12/17 A,_,„ DEtiA 8 2017 -
(if known) (7) r.,
Reason for original issue of Warrant/Check (8):
▪ Payroll CLERK MARICOPA BOARD OF COUNTY SUPERVISORS
IR For Services or Goods furnished Bus Repairs
• Other:
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999