112917 DUPLICATE WARRANTS 12.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: 11/1/2017
Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the
next available Board agenda
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 Santa Theresa Alday #180022189 $435.89
#05 Isaac School Rodolfo Urquiza Jr #180023726 $721.07
#65 Littleton ESD Kiyomi Hollingsworth #480012801 $13.00
RECEIVED
NOV 0 3 2017
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS ,

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.
ALDAY, SANTA THERESA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 10/20/2017 (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 $ 435 . 89 .(3 )
Signed: ALCIa4 cA Xot,k-rit - (4)
. ion r to before me this 1 day of 20
et 1
TARY PUBLI
OFFICIAL SEAL
Mx commission expires: Notary BARBARA Public M. - Arizona GILL
of-A_Lt-ic:20)ci My MARICOPA Commission COUNTY Expires seal)
AUGUST 14, 2019
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 45230505
(if known) (6) — _—
Original Date of Issue II I
10/20/2017
(if known) (7)
Reason for original issue of Warrant/Check (8): CLERK. MARICOPA SOAR:\ OF COUNTY SUPERVISORS
Payroll
0 For Services or Goods furnished
0 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 & 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.
gdolfQ p Urquia zl: (1), being first sworn, upon oath deposes and says:
ame al ant
On or about OC.-61012.r 27 26/7(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/checki,s5u0 to him/her in the sum of $ 1 Z. I • 01 .(3)
Signed: or- (4)
(5) Subscri ed and sworn tp \ before me this '(-) day of ((. .-1--0 )2a1( 20 1 -1.
NOTARY PUBLIC OFFICIAL SEAL
SANDRA APONTE i
My commi,sion pxpires: Notary Public • State dArizarta
MARICOPA COUNTY
pD,-.0 MY Comm, Expires/40111, 2020 (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
(if known) known) (6) 1 0.002.. -72I
Original Date of Issue
(if known) (7) 10 l zu h --/ DATi I A1911:1, _
Reason for original issue of Warrant/Check (8):
xf Payroll MARICOPA COUNTY
El For Services or Goods furnished
111 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 & 15-999

Stop Payment
• vscou-- Affidavit
Business Resources
STATE OF ARIZONA
COUNTY OF MARICOPA
qK BOARD OF SUPERVISORS
MARICOPA COUNTY
Kiyomi Hollingsworth , being first duly sworn, upon oath deposes and states:
That on the 2 day of August , 20 17 , he/she presented to Littleton Elementary
School District No. 65, of Maricopa County, for payment, a claim for services rendered or supplies furnished during
the month of July , said claim being in the sum of Thirteen
Dollars ($ 13.00 ) in payment of which Littleton Elementary School District No. 65 caused warrant/check
number 480012801 to be issued on 8 day of August , 20 17
drawn on the warrant/check fund of Littleton Elementary School District No. 65 of Maricopa County, Arizona.
Affiant further states that although he/she was informed and believes that the above mentioned warrant/check
was regularly issued, the same has never been received, or has been lost.
Wherefore, affiant requests that the Governing Board order and the Littleton Elementary School District No. 65 issue
to him/her a replacement of said warrant/check number480012801 in the sum of $ 13.00
Subscribed and sworn before me this , 20
OFFICIAL. SEAL
RAQUEL FLORES
Commission #274462
Notary ubIIc • State of Arizona
I-71 My cornrr4 MA expires ICOPA March COUNTY 1.2019
My Commission Expires
03/2013