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RECEIVED 44017 INTEROFFICE MEMORANDUM MAFIICOPA COUNTY GlaER14430 PEIRVISORS 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: 10/11/2017 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, #79 Litchfield Elem Dance Gallerie Performance Center #470063040 $700.00 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. Dance Gallerie Performace Center (I), being first sworn, upon oath deposes and says: Name/Claimant On or about 1/19/2017 (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 issued to him/her i the sum of $ 700.0 .(3) JP Sign d:4 A' (5) Suicribed and sworn to before me this ilYr14 day of 20 1—+. NOTARY PUBLIC Rachel Julissa Ruiz My commission expires: 04.) t)1201q Maricopa Notary County, Public Arizona 1/19/2017 My Comm. Expires 04-13-19 (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 4-7-0063040/79710477 (if known) (6) Original Date of Issue 1/19/2017 (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll For Services or Goods furnished 111 Other: SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc A.R.S. 11-632 & 15-999 Revised June 2015