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INTEROFFICE MEMORANDUM RECEIVED Waricopa County School -Superintendent's Office MAY 1 2 2017 TO: (LEV( OE TOE 00AX7) MAFIICOPA COUNTY CLERK BOARD OF SUPERVISORS FROM: Willie Thompson SUBJECT: Affidavits DATE: 5/12/2017 Pase find attached 4 Affidavit/Xotice of Craim(s)for Cost 'warrants for incrusion on the net avaifaôfe Ooard agenda The attached item(s) have 6een researched to ensure that the warrant(s) in question have not 6een cashed or previousfy re-issued 4 The original-warrant(s) have had a stop payment done. If you have any questions, prease contact Millie Thompson at 372-1244 or via e-mail - at mthompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed back to the Superintendent of School - Einance Division at 4041 X. Central . Avenue #1200, ( 12 th Troor) Thankyou. #25 LIOERTT JENNIFERMT $ 28. 00 #9 WICKENOVRG AN -MT* CARLSON . $103.18 #33 M.)CKETE ELE514 OLVE R1 -000. AWARDS $121.20 #79 LITCHFIELD MATER /4Z RYON -DATION - $580.00 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. (1), being first sworn, upon oath deposes and says: Name! aimant On or about -07•0'd.0/0 (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 warranticheck,Xsued tc) him/her in the sum of $ .(3) Signed: (4) (5) Subscribed q'nd)sworn to before me this day of 20 NOTARY PUBLIC PUBLIC DEVY L. AKIN — My commission expires: Notary Public -State of Arizona 'bp (1 MARICOPA COUNTY (seal) My Comm. Expires Nov.30,2017 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 (if known) (6) 11100A3° Original Date of Issue AI known) 7 o1 '13-ko I3 Reason for original issue of Warrant/Check (8): 0 Payroll LII For Services or Goods furnished Other: f(ae.1 • bX4'N,/)i- /\. 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 WICKENBURG UNIFIED SCHOOL DISTRICT NO. 9 4:r 40 W. Yavapai, Wickenburg AZ 85390 Phone (928) 668-5350 Fax (928) 668-5390 111 cHAmpioNs — Mk — CHILDREN AFFIDAVIT nclreilo Car lso-n being first duly sworn, upon oath deposes and sa ys: That on the 3 day of 2011P, he presented to Wickenbur g Unified School District #9 Maricopa County, for payment, a claim for services rendered or supplies furnished durin g the month of J ut , said claim being the sum of Dne 141.411fili-C,d Dollars ($ O3 . (q ) in payment of which the Superintendent of Schools caused Warrant # I 11)00 37 to to be issued on 3 - 2 , 20 / , drawn on the 5'1 IP fund of Wickenburg Unified School District #9 of Maricopa Count y, Arizona. Affiant further says that although he was informed and believes that the above mentioned warrant was re gularly issued, the same has never been received, or has been lost. Wherefore, affiant prays that the Board of Supervisors order and the Superintendent of schools issue to him a duplicate of said Warrant # nob() 37/Din the sum of $ 10 . Signature: Subscribed and sworn before me this 48 day of roay , 20 I 1 . VGALu ShA14,,u Notary Signature Commission Expiration Date 4,.....••I•I••I•I•••I•••I••1 . ,dran_bt. -0 VALARIE SHUM WAY Notary Public - Arizona Maricopa County Following Notary approval please return original affidavit to: My Comm. Expires Oct 7, 2018 Wickenburg Unified School District • • • ••• Accounts Payable AP I ' 40 W. Yavapai Street Wickenburg, AZ 85390 LERK, BOARD OF SUPERVISORS MARICOPA COUNTY Affidavit STATE OF ARIZONA ) ss. COUNTY OF MARICOPA ) Blue Ribbon Awards being first duly sworn, upon oath deposes and says: That on the 16th day of December , 2 016 , he/she presented to the Buckeye Elementary School District #033 of Maricopa County, for payment, a claim for services rendered or supplies furnished during the month of December , said claim being in the sum of One Hundred Twenty-One and 20/100 Dollars ($121.20) in payment of which Buckeye Elementary School District #033 caused Warrant No. 4-7-0053612 to be issued on December 22 , 2 016 , Drawn on the 040 Fund of Buckeye Elementary School District #033 of Maricopa County, Arizona. Affiant further says that although he/she was informed and believes that the above men- tioned warrant was regularly issued, the same has never been received, or has been lost. WHEREFORE, affiant prays that the Board of Supervisors order and the Buckeye Elementary School District #033 issue to him/her a duplicate of said Warrant No. 4-7-0053612 in the sum of $ $121.20 Signature: Subscribed and sworn to before me this Kellsi Williams Notary Public 27 day of , 2 017 Maricopa County, Arizona My Comm. Expires 426222020 Notary Public: My commission expires: OOP-7/2-O2 Following approval please return this affidavit to Maricopa County School Superintendents Office. 41 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. Pioneer AZ Foundation (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 03/23/2017 (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/che,c* be issueci to him/her in the sum of $ 580.00 .(3) Sign (4) (5) S scri,bed and sw n to before me this day of (\f\c---3 20 \ . ARY PUBLIC NIKOLINA VISNJIC.SILVA I Notary Public in and for I M common expires:_ State of Arizona couNtseal I MARICOPA L NIv Commission Expires _s cr 14_2020i 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 470082301/79711846 5 i.r 1 (if known) (6) / / Wirfr 1; Original Date of Issue 03/23/2017 (if known) (7) Reason for original issue of Warrant/Check (8): CI Payroll For Services or Goods furnished FIELD TRIPS Ar\Tr) rvrrsr D Other: S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc A.R.S. 11-632 & 15-999 Revised June 2015