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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED SEP 1 2 2017 MARICOPA COUNTY TO: CLERK OF THE BOARD CLERK BOARD OF SUPERVISORS FROM: Terri Ysaguirre SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 9/12/2017 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.vsaguirre@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. #59 Laveen Elem Harriett Portfield #170029357 $137.23 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: gl Duplicate or El Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this Ioy.rnr correspond to numbers on the COUNTY OF MARICOPA Instruction sheet \yr/ is page 2 of this form. Harriett Portfield (1), being first sworn, upon oath deposes and says: Name/Craimant On or about November 10, 2016 (ziate)(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/checl be issued to him/her in the sum of $ 137.23 .( 3) Signed: (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 20 fr-7 LA NOTARY PUBLIC U affABETH S011104114ENE1 Noy P. Stide olAtiama My commission expires: MY ICARICOPA COnvnimion COUNTY Expires May 30, 2019 (seal) Warrant/Check Number 170029357 (if known) (6) Original Date of Issue November 10, 2016 APPEL (if known) (7) Reason for original issue of Warrant/Check (8): Payroll RK, MARICOPA BOARD OF COUNTY SUPERVISORS El For Services or Goods furnished LI Treasurer's refund/payment 0 Other: S:\PROCESSES\Warrants - Duplicate or Stale \02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644