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INTEROFFICE MEMORANDUM Ytlaricopa County School -Superintendent's Office TO: CLERIC OE TOE OOARD FROM: .Wirlie Thompson SUBJECT: Affidavits DATE: 3/23/2017 PThase find attached 2 Affidavit/Notice of Craim(s)for Cost warrants for inclusion on the nek-t availa6 oard agenda The attached item(s) have deen researched to ensure that the warrant(s) in question have not 6een cashed or previously re-issued The original- warrant(s)thave had a stop payment crone. If you have any questions, please contact Thompson at 372-1244 or via e-mail at mthompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed back to the Superintendent of School finance (Division at 4041 W Central-)4venue #1200, ( 12 th (Floor) Thankyou. #44 AVONDALE SOVLWEST ACADEMY $6887.22 #216 AGVA EWA CHELSEA I 00ERST511A $1028.66 #5 ismc gymereifEwALT9miv - svcooc7I $872.70 ECEIVED MAR 2 3 2017 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS 1-1 1-\\ u 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. 14 444- Iv2 uu A 11-tvlan -5 u ilvdc( ), being first sworn, upon oath deposes and says: Name/Claimant On or about 140,rck 2 2 2.0 1 (date) ( )(2) (2) a warrant/check was issued to the 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 $ 7 1 70 .(3) Signed: 1,40,• e- (4) (5) Subscribed and sworn to before me this 2'.2-**4 day of tMgjgk 20 11 . NOTARY-PUBLIC OFFICIAL SEAL RYAN FRENCH ! My cornmissicin expires: Notary Pubftc- State ofkizona ‘4,9 MAR1COPA COUNlY SI 13 7.9 Zo • 4:11-ii-0 My Comm. Bwires Mardi 13, 2020 I (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 (if known) (6) 1 --100 14 19 5L 1 Original Date of Issue 1 1 (if known) (7) Reason for original issue of Warrant/Check (8): MAR I 4 2017 DAT 1:1 For Services or Goods furnished 'ER K AF; .7) " SUPERVISORS MAR , COPi\ CCUN Y LI Other: 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 frit/ 6.P/ 3111 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form oi This application is for: Duplicate or LI 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. 4,enulltiboersPyy\cit (1), being first sworn, upon oath deposes and says: On or about 7 f I ie (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 (ob warrant/check be issued to hi her in the sum of $ \-b" 1 - .(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) Sub 01 ibed and sworn to before me this 1 -14-‘day of co-'4 tor N_C;TARY PUBLIC JONATHAN U KELLY Notary Public - Arizona My co7Imiss / n . ei expires: Maricopa County My Comm. Expires Oct 29, 2019 ler•I•I••I•I•I•II•••I•I4111P Warrant/Check Number 003;13 g? (if known) (6) Original Date of Issue i l l 1 7 1 1 tp (if known) (7) Reason for original issue of Warrant/Check (8): F.14 Payroll 0 For Services or Goods furnished 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 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. 50uKw.e54-- Name/Claimant (I), being first sworn, upon oath deposes and says: On or about rzior) zo I (a (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 $ (At+. ZZ- .(3) Signed: (4) (5) Subscribed and sworn to before me this / —I day of 076k 20 17. . A1,4411‘. -- OTAFY PG: MARCI HIGGINS My commission expires: Notary COCONINO Public - Staki COUNTY of Arizona ry My Commission Expires (seal) March 17, 2018 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) 1/7-00i4 T9 7 Original Date of Issue (if known) (7) 12//o/ / i te Reason for original issue of Warrant/Check (8): APPROVED CI Payroll DATE MA; 2 42i7 For Services or Goods furnished if CI Other: W INN" - MI,FilCOPA COUNTY SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of daim.doc Revised June 2015 A.R.S. 11-632 & 15-999 SOUTHWEST ACADEMY 3/10/2017 Dear Ms. Hall: Kathy Burwell is authorized to sign the Schools Affidavit/Claim Form on behalf of Special Education Services DBA Southwest Academy. Sincerely, Brian McGowan CFO Special Education Services The Menta Group Special Education Services • An Affiliate of The Menta Group® 4018N. 67th Ave • Phoenix Arizona 85033 • (623) 849-8511 • Fax (480) 454-8750 www.thernentagroup.org • PIViorgan • Chase sank, .; REN AR:Ft _ 15.hci.9(4x. :$17.171EASt).. A CO PHOENIX, ARIZONA' 91z2P(221 " DATE CONTROL NO. THIS INTEREST WARRANT STOPS DRAWS ON DATE INTEREST FUNDS FROM AVAILABLE. DATE (SEC MARKED 11-636, INSUFFICIENT ARS1956) FUNDS' 12/01/2016 216704233 0 Agua Fria Union High School District #216 WARRANT AMOUNT a P4Y. *six Thousand Eight Hundred Eighty Seven and 22/100*** Dollars $6,887.22 d. Include DAYS SOUTHWEST ACADEMY ures TO THE 4022 N. 67TH AVENUE ok6INTJ-1,/ ORDER PHOENIX, AZ 85033 Dr. Donald Covey Superintendent of Schools OF AUTHORIZED SIGNATURES 04700467990 1:1 2 2 L000 241: 9 70 4 3 9 4 9 311' 12101/2016 Check: 216704233 EXPENSE MARICOPA COUNTY SCHOOLS • PHOENIX, ARIZONA AP 12-2-16 470046799 SOUTHWEST ACADEMY 12/01/2016 I Payee Check Date Account Number PO Number Invoice Amount 221200100065635005070000 170872 T0L000250 344.40 221200100065635005070000 170872 T0L000894 2,797.20 221200100065635005070000 170872 TOL000895 3,745.62 0 VOUCHER: 7038 TOTAL: $6,887.22 HARLAND CLARKE M22692 60126026