121317 DUPLICATE WARRANTS 10.PDF

RECEIVED
NOV 272011
INTEROFFICE MEMORANDUM
CLERK Mil-11-'01";;',-k Le TrY
Maricopa County Education Service Agency (aka BORE (Dr= !1.I.PERVISORS ,
Maricopa County Superintendent of Schools Office) Vet-i
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TO: CLERK OF THE BOARD
FROM: Terri Ysaguirre
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 11/22/2017
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.
#45 Fowler Elem Theresa J Zimmerman #180026797 $334.92

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.
ZIMMERMAN, THERESA J (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11-04-2017 (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-6fiim-- er in the sum of $ 334 .92 .(3 )
Sig e kaa.i/J/ 14/4_ (4)
before me this /CA- dayco_f_AO 20±;
NOTARY PUBLIC
cgmnnission expires: BARBARA OFFICIAL M. SEAL GILL
Notary Public - Arizona (seal)
MARICOPA COUNTY
My Commission Expires
AUCIUb I 14, (./1 9
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) 45231283 - - - --------
Original Date of Issue ,i;;\ j . ' i Lc,:'_\ .,:,-,) v ,,, ,
(if known) (7) 1 1-04-2017 0 91117
Reason for original issue of Warrant/Check (8):
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 8/.15-999