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INTEROFFICE MEMORANDUM Waricopa County School -Superintendent's Office TO: CLEV(OE TOE 00ARD FROM: WitTie Thompson SUBJECT: Affidavits DATE: 3/28/2017 Pase find attached 2 Affidavittg\rotice of Craim(s)for Cost warrants for indusion on the ne4 avaifaôle Ooard agenda The attached item(s) have 6een 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. lf you have any questions, please contact Mine Thompson at 372-1244 or via e-mail at at mthompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed back, to the Superintendent of School - Finance Division at 4041 X. Central- _Avenue #1200, ( 12 th Efoor) Thankyou. #66 ROOSEVELT AWITA cOTIERREZ $216.16 #68 ALY -05110M DIANAKUOI XAVA LOPEZ $555.04 RECEIVED MAR 2 0 2017 MANCOPA COUNTY CLERKBOAFiD OF Si JPERV1SORS 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. Anita Gutierrez (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 31 ke ( 1 1 (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 $ 216.16 .(3) Signed: k;lip (4) (5) Subscribed and sworn to before me this a.;) day of \i\c),t C_\A 20 1?. CuvO NOTARY PUBLIC Notary Public State of Arizona Maricopa County My commission expires: My Marisa Commission A Brito Expires 07/0312017 -70/Q00 (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 170056790 31 (if known) (6) 2 A _ I 1 Original Date of Issue 3 I Ici I 1 -7 of (if known) (7) K, BOARD OF SUPERVIS04— Reason for original issue of Warrant/Check (8): MARICOPA COUNTY 14 Payroll El For Services or Goods furnished 12" Other: Cillt9Injet fr—± jjer ahe 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 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. DIANA RUBI NAVA LOPEZ (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 3-9-17 (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-b is,1 to him/her in the sum of $ 555 .04 .(3) , Signed: (4) (5) Subscribgclan51-sw_orn to4efere me this 24TH day of MARCH 20 17 . NOTARY PUBLIC J;77,7nniiripMtkis: (seal) ":7( mARIcoPAcouY NT: .'46--40.-- inel11•01....11•104.••••• • - v.• •••••••••••I•••11.100.1M1•11 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 170055344 (if known) (6) A P Original Date of Issue 3_9_ 17 1 jilfeLqtri (if known) (7) DAT501 Reason for original issue of Warrant/Check (8): BOARD OF SUPERVISORS Payroll MARICOPA COUNTY III For Services or Goods furnished 111 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