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INTEROFFICE MEMORANDUM Maricopa County Education Service Agency (aka Maricopa County Superintendent of Schools Office) RECEIVED AUG 1 1 2017 TO: CLERK OF THE BOARD MARICOPA COUNTY CLERK BOARD OF SUPERVISORS FROM: Terri Ysaguirre SUBJECT: Affidavits — Replacement of Lost Warrants DATE: 8/10/2017 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 theresa.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 Sara Nicholas #170083666 $441.82 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: CI Duplicate or 0 Stale-Dated (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. Sara Nicholas (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 6/30/2017 (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 $ 441.82 .(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 flo- 20 I 3 . BRITTANY CARTER Notary Public My commission expires: Maricopa County, AZ 02c/ ,)( My Commission Expires (seal) April 29, 2019 Warrant/Check Number 170083666 (if known) (6) Original Date of Issue 06/30/2017 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll CLERK, BOARD OF SUPERVISORS El For Services or Goods furnished MARICOPA COUNTY 0 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