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MCESA Maricopa County Education Service Agency INTEROFFICE MEMORANDUM Maricopa County Education Service Agency TO: Clerk of the Board FROM: CARRIE GUNDERSON SUBJECT: Affidavits — Replacement of Lost /Stale Warrants DATE: 1/19/2017 PLEASE FIND ATTACHED 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. 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 ciarnishnnents@mcesa.maricopa.gov . Approved Affidavits may be routed back to the Maricopa County Education Service Agency at 4041 N. Central Avenue #1200, (12th Floor) Thank you. Fund 781 SUSAN PORTILLO 170041655 Dated 12/21/16 for $641.65 RECEIVED JAN 2 0 2017 MI.F COPA COUNTY CLERK BOAHD OF SUPERVISORS 4041 N. Central Avenue, Ste. 1200, Phoenix AZ 85012 • Phone 602-506-3866 • Fax 602-506- 3753 www.maricopa.gov/mcesa Twitter: #mcesaaz Facebook: mcesaaz Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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. SUSAN PORTILLO (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/23/16 (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_himMer in the sum of $ 641.65 .(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 I day of nuccivi 20 LT NOTARY PUBLIC BRITTANY CARTER Notary Public My commission expires: Maricopa County, AZ Tpr1 (9.c1t 00ict My Commission Expires (seal) April 29, 2019 170041655 Original Date of Issue 12/21/16 (if known) (7) Reason for original issue of Warrant/Check (8): IU 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 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: 1/19/2017 Please find attached 5 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. #5 Isaac Maria Candelaria Quintana Garcia $143.76 #216 Agua Fria Cory Deal $1553.97 #21 Murphy Bryan Borden $257.26 #68 Alhambra Jennifer Bunch $2139.82 #79 Litchfield Thomas Whiles $422.38 RECEIVED JAN 20 2017 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS 10 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. Ofitighvn kezid Meo avablffl, being first sworn, upon oath deposes and says: Name/Claimant On or about i9iIM4 / O/ 7 (clate)(2) a warrant/check was issued to the above named person/e tity 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 $ 113.76. .(3) Signed: _(4) (5) Subscribet1 Ond sworn to befQre me this / .l' day of 20 r NOTARY PUBLIC iii OFFICIAL SEAL 1 SANDRA APONTE My commissiorp expjres: Notary Public - State ofArizona 1, ao s<zaro..7 My Comm, MARICOPA EvIraa April COUNTY 11, 2020 (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 / 10VAave ' l (if known) (6) Original Date of Issue /p.(470/ (if known) (7) 0 / 7 Reason for original issue of Warrant/Check (8): 1=1 Payroll 1=1 For Services or Goods furnished 0 ,= - SUPERVISORS 0 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 AFFIDAVIT APPROVED DATE,/ JA) 20 207 STATE OF ARIZONA K, BOARD OF SUPERVISORS COUNTY OF MARICOPA MARIGOPA COUNTY 1 cAq_ Jr/ , being first duly sworn, upon oath deposes and says: That on the rridav of T-14120 0-, he presented to District of Maricopa County, Arizona, for payment, a claim for services rendered or supplies furnished during the month of AibveiviGEP-- 20. , said claim being in the sum of Dollars, ($ J(? ' /7) payment of which the Superintendent of Schools caused his/her Warrant Number 0?/6/703 411/ / to be issued on /1 / , 20 P., , drawn on the at Fund of District of Maricopa County, Arizona. Affiant further says that although he/she 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/her a duplicate of said Warrant Number o tla o / the sum of $ C-2 -97 Subscribed and sworn to before me this SirtA day of ,20 11 OFFICiAL ; 6t2t - DIANA CRAFT 1 Notwy RE4c- Stile d Mare I 7 My MARICOPACOUNTY Corm Evan, Fib. 11,4DIA I I. NOTARY PUBLIC Op I 6 Following approval please return this affidavit to the Maricopa County School Superintendents Office. 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. BRYAN BORDEN (1), being first sworn, upon oath deposes and says: Name/Claimant On or about Ir2J og_1690 (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 er in the sum of $ 257.26 .(3) Signed: (4) (5) SuOSCFIDE d anE worn to before me this / 74- o 7. Z2 i-cL 6z- Q---e--- NW 13 UBLIC OFFICIALSEAL ; wawa Jr/ Notary BARBARA Public - State GRACIA afArtzone I j My comjnision vpires: IVIARICOPA COUNTY 0 vpvc,70/ e t. My Comm. Blares Sept 18, 2018! (seal) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. ,ily • Warrant/Check Number 47-0047815 iN 2 0 9i7 (if known) (6) Original Date of Issue 12/02/2016 (if known) (7) ••e'',Q^ CLERK MARICOPA - COUNTY Reason for original issue of Warrant/Check (8): El Payroll • For Services or Goods furnished ACCOUNT PAYABLE LI Other: ACCOUNT PAYABLE 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. Jennifer Bunch (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 7 Ra (date)(2) a warrant/check was issued to the above named pers n/ent ty 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 issued to him/her in the sum of $ 2,139.82 .(3) Signed: (4) (5) Subscribed and sworn tO befia(rej me rs /DA day of 20 / NOTARY PUBLIC — OFFICIAL SEAL : CHERYL CARDER My co7m7ion expdes: Notify Public • Sate of Ancona 0 1 -7 My MARICOPA Comm. Expires COUNTY Aug. 12 2017 (seal) 4.1.1I 0 •1111I••••••• I 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 11 00b 3ctco 3 (if known) (6) Original Date of Issue DAT_ A 0" (if known) (7) 07/25/2016 ,---"- Reasop for original issue of Warrant/Check (8): ERK. MARICOPA BOARD OF COUNTY SUPERVISORS Payroll III For Services or Goods furnished El 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 8c 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. rCF . L.jiott_S (1), being first sworn, upon oath deposes and says: Name/Claimant On or about /12' / .01 6 (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 $ 1/2-?-, 35 .(3) Signed: (4) (5) Subscribed and sworn to before me this day of 20 . NOTARY/PUBLIC BRITTANY CARTER Notary Public My commission expires: Maricopa County, AZ Hrri 3.(it, orc )icf My Commission Expires( 'Seal) April 29, 2019 Note: Please attach a copy of the warranVcheck if available and/or any other evidence that a Pvarrant/check was originally issued. Warrant/Check (if known) Number (6) /760 L// Li Li 7i 717/0/J Original Date Date of Issue (if known) (7) a m iffa dAl. "iiP i.;" 1" Reason for original issue of Warrant/Check (8): Payroll LI For Services or Goods furnished IAIRD OF SUPERVISORS VARICOPA COUNTY CI 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