112917 DUPLICATE WARRANTS 10.PDF

INTEROFFICE MEMORANDUM
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: 11/2/2017
Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the
next available Board agenda
if 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.
#33 Buckeye Elem Amy Bernice Blaylock #180020395 $806.75
#25 Liberty Elem Ruby Acuna #480021797 $121.71
RECEIVED
NOV 0 3 2017
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
,
c)

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.
(1), being first sworn, upon oath deposes and says:
LijamA(AlinCfr--
On or about 17 ,.// /1/ (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 $ fc 1. 7 .(3)
Signed:
(5) Subscribed anchsworn o before me this c).:144A day of Dc t ILL- 20 11
Gc.)
NOTARY PUBLIC Karina Matsuura
Notary Public - Arizona
MARICOPA COUNTY
My commission expires: My Commission Expires
17- 2-0/B December 7, 2018 (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 7
if known 6 qe.. 00 1) 1 . d5-`007/
Original Date of Issue / 611.7
if known) (7)
A
Reason for original issue of Warrant/Check (8):
I=1 Payroll
111 For Services or Goods furnished al:ARV
CLERK, BOARD OF MMILAPTZ. SUPERVISORS 14(.41,
Other: 'tt MAPDCOPA 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

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.
Amy Bernice Blaylock (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 10/12/2017 (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 $806.75 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this oTTILli day of Octhober 20 ( .
NOTA"BLIC
APRIL A. RHODES
Notary Public - Arizona
My commission expires: Marlcopa County
10/12/2017 13e_ec . c (3. My Comm. Expires Dec 3, 2018 (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 1-8-0020395
(if known) (6)
Original Date of Issue 10/12/2017
(if known) (7)
DA1
Reason for original issue of Warrant/Check (8):
— Payroll CLERK, MARICOPA BOARD OF COUNTY SUPERVISORS
El For Services or Goods furnished
El Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc A.R.S. 11-632 & 15-999
Revised June 2015