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MCESA Maricopa County Education Service Agency INTEROFFICE MEMORANDUM Maricopa County Education Service Agency TO: Clerk of the Board FROM: CARRIE GUNDERSON SUBJECT: Affidavits — Replacement of Lost /Stale Warrants DATE: 10/31/2017 PLEASE FIND ATTACHED AFFIDAVIT/NOTICE OF CLAIM(S) FOR LOST WARRANTS FOR INCLUSION ON THE NEXT AVAILABLE BOARD AGENDA. 'NI 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 garnishmentsmcesa.maricopa.gov . Approved Affidavits may be routed back to the Maricopa County Education Service Agency at 4041 N. Central Avenue #1200, (12th Floor) Thank you. Fund 781 Deborah Viramontes 180021315 Dated 10/12/17 $998.62 RECEIVE OCT 3 1 2017 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS 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 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. ), being first sworn, upon oath deposes and says: On or about 2.401i(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 sued to him/her in the sum of $ 54q d .(3 ) 012i.) / SE-Irryle-hPr Signed: (4) (5) Subscribed and sworn to before me this day of OcAo e-r 20 . QA- FAckoWfoc NOTARY PUBLIC KELLY BLACKHAM My commission expires: Noisy MARICOPA Public - State COUNTY of Arizona rq la I aov My Cifeettiber Commission 2, 2017 Expires (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 I gee ?A - 2)-1 , (if known) (6) Original Date of Issue (if known) (7) lUct/Aki Reason for original issue of Warrant/Check (8): APPROVED X Payroll DATE NOV 1 20" LI For Services or Goods furnished CLERK ROARD OF SuPEPVISORS El Other: MARICOPA COUNTY S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc Revised June 2015 A.R.S. 11-632 & 15-999