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RECEIVED SEP 1 5 2017 INTEROFFICE MEMORANDUM MAR1COPA COUNTY CLERK BOARD OF SUPERVISORS 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: 9/14/2017 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. #25 Liberty Elem Shane Darr #470028519 $25.00 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. >ftetelac, Darr (1), being first sworn, upon oath deposes and says: ame/CI !man On or about Od 01N0/6 (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 $ c15: 00 .(3) Signed: (4) (5) Subscribed and sworn to before me this 7 day of GQA--,t.Q),20 1 .7 NOTARY PUBLIC MY LAKIN Notary Public- State of Arizona My commission expires: MARICOPA COUNTY biD---0 My Comm. Expires Nov.30, 2017 (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 i / r 706 021,5-1 1 1 (if known) (6) APPLoyiE Original Date of Issue 9'11 ,1 bat' (if known) (7) 10/11/0Z0/(0 DATA Reason for original issue of Warrant/Check (8): LIPayroll ps , For Servic or Goods furnished g Other: 4-161 IX~ 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