011718 DUPLICATE WARRANTS 14.PDF

INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office) RECEIVED
DEC 22 2017
MARICOPA GCLIN•Pf'
TO: CLERK OF THE BOARD CLERK BOAFD OF ::::,..:PEFIVISORS
14(q
FROM: Terri Ysaguirre
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 12/20/2017
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 terriNsaguirre@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.
#44 Avondale Elem Elva AD Grijalva Garica #180028772 $1,478.22

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El Stale-Dated (definitions are on page 2)
STATE OF ARIZONA: :Nate: Nagibee.wan fOitrr correSPaRdld ritimbers -
Q011.14TY OF MARICOPA. slnatruAtiaa sheet .vii.hipti:14134ge 2:P1411-a-tit?.
gLNA.GRLIALVA -Nameietairnapts ,(1),:being first' sworn, :up.on oath deposes. and ,says::
On or -about: 11 /1 001 7 (clat)R) .a warrant/check. was. issued to the
named, person/entity in the amount as stated below ,..- :Such 'warrant/Check Was
either never received or was subsequently inadvertently lost Of destroyed and there is
no .reasonable probability of its being found orpresentsti .fpr .payment, or it was not
:presented foevayniont with UI one year after the date ofissuance:
Therefore, under sperlaity of perjury,. claimant hereby affitThs that this claim . IS 'totted
and the.amount shown isdue .and oWingi.and the. applicanttecpeits..thata replacement
Wairantichecit..beisSupd: to him/ erin the-sum of .$.1 48.4 .(3)
Signed: 4' (4)
Note: Please.attai I a copy of the wanwnVchick if available and/or any other
evidence that a warrant/check was originally Issued
c* of er 1,
My COMM-IsiOn expires: sTATE NOTARy:eusup ,oFAmorslA
\ Ott i mar16*k art_
MONICA LASS
Warrant/Check Number iffMiftffMiti9PLier
(irknowd)'(6). 180028772
.gitit141.Pate.:03SStle (Irknown):C7) •11/16/2017
Reason for original issue cif Warrant/Check (8): 2 6 2017
Payroll
0 For Services or GOods furnished LERK BOARD OF SUPERVISORS
0 Treasurers refund/payment
U. Other;
.80KOttssES‘Warratits Revised Aprfl 2015 ,, bgliiicatevr*e\02.F00114‘WalranOth005 . . hOticetterairit- b*dpe.
AsIta 11'632 64 11-644