021517 DUPLICATE WARRANTS 1_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
Fr m: Wanda Childers
Date: January 17, 2017
Re: Replacement of Lost Payroll Warrants
Please find attached 2 Affidavit/Notice of Claim(s) for lost
payroll 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.
Please call Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: • Duplicate or 1=1 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.
Kathy S. Upchurch (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about November 30, 2016 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 s;.Jm of $ 140.00 .(3)
Signed: 4'alk4 (4)e1i246 (4)
Note: Please attach a dbpy 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 day of 7)c,,Avq07
_----_-__
BEN SEGAL
Notary Public - State of Arizona
My comm, i4on expires: MARICOPA COUNTY
cakt-f ) My Commission June 24, 2018 Expires (seal)
Warrant/Check Number 22
(if known) (6)
Original Date of Issue 11/30/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
O Other: CLERK, MARICOPA BOARD OF COUNTY SUPERVISORS_
Revised April 2015 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: g Duplicate or El 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.
Elizabeth Akuch Aguer (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 11/30/2016 (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 $ 140.00 .(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 t-1(1' day of )&n Vart)_ 20 n .
arissa Espinoza
Notary Public
Maricopa County, Arizona
My commission expires: My Comm. Expires 08-25-19
epct (seal)
Warrant/Check Number 22436848
(if known) (6)
Original Date of Issue 11/30/2016 3>
(if known) (7)
Reason for original issue of Warrant/Check (8): Fri
UI Payroll V
El For Services or Goods furnished 1 9 2017 — — Oa
111 Treasurer's refund/payment
Eli Other:
Revised April 2015 A.R.S. 11-632 & 11-644

INTEROFFICE MEMORANDUM
Maricopa County Education Service Agency (aka
Maricopa County Superintendent of Schools Office)
TO: CLERK OF THE BOARD
FROM: Denise Weihe
SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 1/17/2017
Please find attached 2 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the
next available Board agenda
V The attached item(s) have been researched to ensure that the warrant(s) in
question have not been cashed or previously re-issued.
V The original warrant(s) have had a stop payment done.
If you have any questions, please contact Denise Weihe at 602-372-1245 or via e-mail at
denise.weihe@mcesa.maricopa.gov . Approved Affidavits may be routed back to the
Superintendent of School Finance Division at 4041 N. Central Avenue #1200, (12th
Floor) Thank you.
#60 Higley West Music $1602.37
#9 Wickenburg Annette Roberts $49.91
/0

Schools Affidavit/Claim Form
Application fo a Duplicate Warrant/Check (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form borreSpond to numbers on the
COUNTY OF MARICOPA instrudion sheet which is page 2 of this form.
West Music (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or _about "nAiouA-ver zor7 (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/ Lin the sum of $ 1,602 .37 .(3)
Signed: (4)
ibed and sworn to before me this \ day of 20 ,
NOTARY PUBLIC
RYAN WEST
Commission Number 756257
My mromission expires:. Zrjr. 7 My December Commission 17, Expires 2017 (seal)
121 1-1
Note: Please attach a copy Of the warranVcheck If available and/or any other
evidence that a warrant/check was originally issued
Warrant/Check Number 470042913
(If known) (6) Da *A/F_____
Original Date of Issue '11 11812016 ,
Reason for :original issue of Warrant/Check (8): ERK, MARICOPA BOARD OF COUNTY SUPERVISORS
0 Payroll
I* For Services or Goods furnished Music. and instruments
0 Other music and instruments
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\SchoolOthOols-Warrants Checks notice of clalm.doc ARS 11-:632 -& 15-099
Revised June 2015

To whom it may concern,
I Heather Owens an Accounts Receiable Clerk with West Music Company have authority to sign
the presented Affidavit confirming that West Music has never received the payment in question.
If you have any questions or need any more information please feel free to contact me at 1-800-
373-2000 Ext 1122.
Thank you
Heather Owens
Accounts Receivable Clerk
West Music Company
1212 5th St
PO Box 5521
Coralville IA, 52241
howens@westmusic.com
1-800-373-2000 Ext 1122

PPROVED
JAIA 9 210.
WICKENBURG UNIFIED SCHOOL DISTRICT NO. 9 DARD OF SUPERVISORS
40 W. Yavapai, Wickenburg AZ 85390 -3ICODA COUNTY
Phone (928) 668-5350 Fax (928) 668-5390
CHAMPIONS
- POR -
CHILDREN
AFFIDAVIT
Ifl fleI-1e... 70/7-60S being first duly sworn, upon oath deposes and says:
That on thefi 41‘day of ) 201 he presented to Wickenburg Unified School District #9
Maricopa County, for payment, a claim for services rendered or supplies furnished during the
month of said claim being the sum of —I) (u di) hax5 (6b
Dollars ) in payment of which the Superintendent of Schools caused Warrant #
U (Ito o Li 10 to be issued on ,20 ),6 , drawn on the 60( fund of
Wickenburg Unified School District #9 of Maricopa County, Arizona.
Affiant further says that although he was informed and believes that the above mentioned
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 Superintendent of schools
issue to him a duplicate of said Warrant # 7tum of $ 1
Signature:
Subscribed and sworn before me this day of Dee., , 20 / (te,
oe
7, A61F(
Notary Signature Commission Expiration Date
VALARIE SHUN/MAY
Notary Public - Arizona
- Maricopa County
My Comm. Expires' Oct 7, 2018 I
Following Notary approval please return original affidavit to:
Wickenburg Unified School District
Accounts Payable
40 W. Yavapai Street
Wickenburg, AZ 85390