072617 DUPLICATE WARRANTS 8.PDF

IAA Co m cEsA
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'OUN't Maricopa County Education Service Agency RECEIVED
JUL 0 5 2017
9.
MARICCRA n :SUPERVISORS
INTEROFFICE MEMORANOMMAR-
Maricopa County Education Service Agency
TO: Clerk of the Board
FROM: CARRIE GUNDERSON
SUBJECT: Affidavits — Replacement of Lost /Stale Warrants
DATE: 7/3/2017
PLEASE FIND ATTACHED 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.
The original warrant(s) have had a stop payment done.
If you have any questions, please contact Carrie Gunderson at (602) 372-4833 opt.3 or via e-
mail at aarnishments@mcesa.maricopa.gov . Approved Affidavits may be routed back to the
Maricopa County Education Service Agency at 4041 N. Central Avenue #1200, (12 1h Floor)
Thank you.
Fund 781
Gena Marie Stackhouse 170079951 Dated 6/7/17 for $181.29
4041 N. Central Avenue, Ste. 1200, Phoenix AZ 85012 • Phone 602-506-3866 • Fax 602-506-
3753
www.maricopa.gov/mcesa Twitter: #mcesa az Facebook: mcesaaz

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 1E1 Duplicate or 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.
GENA MARIE STACKHOUSE (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 6/8/17 (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 bp issued to him/her in the sum of $$181.29 .(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 daytigii itikriz 20 /7 .
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My commissipn expires:
p7/207 ... . .. (seal)
Warrant/Check Number 170079951
if known) (6
Original Date of Issue 6/7/17
(if known) (7)
Reason for original issue of Warrant/Check (8):
II Payroll MARICCPA BOARD OF COUNTY SUPERVISORS
O For Services or Goods furnished
• Treasurer's refund/payment
O 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