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INTEROFFICE MEMORANDUM Waricopa County School -Superintendent's Office TO: CLERK, OE TOE WARD FROM: 9Hitrie 'Thompson SUBJECT: Affidavits DATE: 1/9/2017 Pase find attached 1 Affidavit/Notice of Craim(s)for Cost warrants for inclusion on the next avaiCabCe Ooard agenda The attached item(s) have 6een researched to ensure that the warrant(s) in question have not 6een cashed or previousCy re-issued .\1 The original. warrant(s) have had a stop payment done. lf you have any questions, pCease contact Mate Thompson at 372-1244 or via e-mait at mthompson@mcesa.maricopa.gov . `Approved Affidavits may 6e routed 6ack, to the Superintendent of School - finance Division at 4041 W Central Avenue #1200, ( 12 th ECoor) Thankyou. # AVONDALE ERIN -914C.ALEAR $2868.22 RECEIVED JAN 0 9 2017 CLERK BOARD OF SUPERVISORS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 121 Duplicate or 0 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. ih %ear (1), being first sworn, upon oath deposes and says: Name/Claimant On or about ii - I -7 P01 (ic (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 $ .(3) Signed: 41. 171 vigoo (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 r•I day of 20 11- . LAU, Relson) OFFICIAL SEAL AURA NELSON My commission expires: •E; Notary Public -State of Arizona Decerne-r 01 °1 MARICOPA COUNTY (seal) e • 1r • • • p.m, • ••I•I My • • iI Comm. ••••• • Em. Expires NO INI.•11 OM Dec, • II M111• 28, •=111 2019 ROMEO. Warrant/Check Number (if known) (6) 1 -70D3PL119. Original Date of Issue (if known) (7) )1 - 1 -7 - 1(, Reason for original issue of Warrant/Check (8): 1S1 Payroll 111 For Services or Goods furnished 7__e_771!" C_RK 1•___7•- OF • SUPERVISOR S MARICOPA COuref 0 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