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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED OCT 1 9 2017 MARICOPA COUNTY TO: CLERK OF THE BOARD CLERK BOARD OF SUPERVISORS FROM: Terri Ysaguirre SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 10/18/2017 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. #44 Avondale Elem Sarah Klivans #170032399 $1,119.35 #44 Avondale Elem Joshua Jandreau #170032393 $1,576.18 Application or a uuplicare or btaie-uateo vvarrant/Lneck Affidavit/Claim Form This application is for: Ei Duplicate or 0 Stale-Dated (definitions are on page 2) STATE OF AF--M534teI Note: Numbers on this form correspond to numbers on the COUNTY OF [V— R t Instruction sheet which is page 2 of this form. 5c0f) Klivo6s (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 1) - iCO (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 iss ed to him/her in the sum of $ 1, 117.35' .(3) Signed: r (COW otait,--) (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this day of 0 NOTARY PUBLIC My co on expires: (seal) Warrant/Check Number (if known) (6) I -7DD 323961 Original Date of Issue [DA Oa 2 0 21117 (if known) (7) I 1 - 1 la Reason for original issue of Warrant/Check (8): LEAK, MARCO BOARD PA OF COUNTY SUPERVISORS EL Payroll 111 For Services or Goods furnished El Treasurer's refund/payment CI Other: SAPROCESSES\Warrants - Duplicate or Stale I02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 .s, A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of Ore() On t`Dil Bp-on before me, Chns Pot 1941,L Date Here Insert Name and Title of the Officer personally appeared S(Arc 11 Rene " kl iVeRS m_e(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person' s whose names is/ave‘ subscribed to the within instrument and acknowledged to me that -he/sheftecy executed the same in bi.s/herifftek authorized capacity, and that by N/her/t4vir signaturN on the instrument the person's or the entity upon behalf of which tl% personNkacted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. Natty/ CHRIS [MAE YEUNG - Catfomia WITNESS my hand and official eal. COmmiksitam ClanzleCatstY aims towermnizpvfetiwia _ E21 Signature S YEUNG plic -California Signature o ublic 3e County - on a 2207875 :pires Jul 29, 2021 Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: 14(-664t Ferg) Document Date: mppri Number of Pages: One_ ( Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Sign - hame: Signer me: El Corporate r — Title(s): LI Corporate er — Title(s): O Partner — E Limi 0 General El Partner — LI Limi El General O Individual E Attorn Fact O Individual LI Attor in Fact E Trustee E Guardian or servator 0 Trustee 0 Guardian o onservator 111 Other: O Other: Signer Is Representing: Signer Is Representing: ©2016 National Notary Association • www.NationalNotary.org • 1-800-US NOTARY (1-800-876-6827) Item #5907 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: D.Duplicate or 0 Stale-Dated (definitions are on page 2) STATE OF ARIZONA 1111:: on this form correspond to II lonni the COUNTY OF MARICOPA InL7-..HLIL‘wiff Is page 2 of this tj/1,) A "S A1/1 Ilea/ (1), being first sworn, upon oath deposes and says: Na /Claimant On or about II - Il . i(te) (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 topim/her in the sum of $ I , 616 I g .(3) Signed: (4) Note: Mee& attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. sworn to before me this 1-1/ day of Odeddt) 20 / 7. •lif Ar7 • • • re My commistion expi es: t JUAN Notary MATEO Public COMMONWEALTH OF MASSACHUSETTS (seal) My Commission Expires Klavomber 4 'VP? Warrant/Check Number (if known) (6) I -3 0639 393 Original Date of Issue A 10 10 F. (77) 17 Eli (if known) (7) OC1 2 0 nv IIiy-• cRK, BOARD OF COUNTY SUPERVISORS NAAR!COPA. O For Services or Goods furnished - O Treasurer's refund/payment O Other: SAPROCESSESWarrants - Duplicate or Stale I02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644