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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: 1/31/2017 PLEASE FIND ATTACHED AFFIDAVIT/NOTICE OF CLAIM(S) FOR LOST WARRANTS FOR INCLUSION ON THE NEXT AVAILABLE BOARD AGENDA. •Ni 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 garnishmentamcesa.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 DORA A. VELASQUEZ 170042163 Dated 12/24/16 for $503.66 170038759 Dated 12/10/16 for $503.74 Total $1007.40 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: FADuplicate 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. DORA A.VELASQUEZ (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 12.29.16 AND 12.10.16 (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 him/her in the sum of $ $503.66 AND $503.741 \ • 40 .(3) Signed: iLe-4/d-yi (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 ---7 day of __Ie+-7\., 20/ 7 . NOTARY PUBLIC My commission expires: 5 . MONICA :.ubtic • SW. LOPEZ dArlsons I - MARICOPACOUNT1 f (seal) Expires July 14, 2018 Warrant/Check Number 170042163 AND 170038759 (if known) (6) Original Date of Issue 12/24/16 AND 12/10/16 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll ▪ For Services or Goods furnished O Treasurer's refund/payment El 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