082317 DUPLICATE WARRANTS 10.PDF

INTEROFFICE MEMORANDUM
Ilaricopa County School-Superintendent's Office RECEIVED
TO: CLERK OE TOE (1.30W9) AUG 0 42017
FROM: gPtillie 'Thompson MARICOPA COUNTY
SUBJECT: Affidavits CLERK BOARD OF SUPERVISORS
DATE: 8/3/2017
Pcise _find attached 1 AffidavittArotice of CCaim(s)for Cost warrants for inclusion on
the next availTailfe Ooard agenda
The attached item(s) have been researched to ensure that the warrant(s) in
question have not 6een cashed or previously re-issued.
The original-warrant(s) have had a stop payment done.
If you have any questions, please contact Marie (Thompson at 372-1244 or via e-mail at
nithompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed 6ack to the
Superintendent of School - Einance <Division at 4041 9V". Central-Avenue #1200, ( 12 th
ECoor) Thankyou.
#216 AGVA ERIA VkI514ITED $300,993.81

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'
Schools Affidavit/Claim Form
Application for a Duplicate Warrant/Check
(definitions are on page 2)
COUNTY STATE OF OF ARIZONA Note: Numbers on this form correspond to numbers on the
MARICOPA Instruction sheet which is page 2 of this form.
LIGHTING UNLIMITED
Name/Claimant (1), being first sworn, upon oath deposes and says:
On or about 7/31 / 17 (date)(2) a warrant/check
above named person/entity in the amount as stated below. was issued to the
either never received or was subsequently inadvertently lost Such or destroyed warrant/check was
no reasonable probability of its being found or presented for payment, and there is
presented for payment within one year after the date of issuance. or it was not
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 $ 300,993 - 81
.(3 )
Signed:
(4)
(5) Subscribed and sworn to before me this day of
20
•
NOTARY PUBLIC
OFF1CLAL SEAL
My commission expires: NOTARY KIMBERLY PUSUC STEVENS -ARIZONA
74a33 My Conn. MARI Excints COPA COUNTY Feb. 14, 2021
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
_Cif known) (_6) 480006116
LOriginal Date of Issue
(if known) (7) 7/18/17 AND MAILED OUT 7/19/17
Reason for original issue of Warrant/Check (8):
• Payroll
Wg For Services or Goods furnished NEW SCHOOLS LIGHTING
E Other: NEW SCHOOLS LIGHTING APP cVED
P
w iz r w
5: Revised \PROCESSES\Warrants June 2015 - Duplicate or Stale \ 02 Forms \Schoors \Schools-Warrants Che ks not 7-460 OF SUPFIVISOIR S