020117 DUPLICATE WARRANTS 4_REDACTED.PDF

Maricopa County
Human Resources
Memo
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Vo: Fran McCarroll, Clerk of the Board >e— (r) f- r7 1
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Linda Widner
January 11,2017 Cr)
Replacement of Lost Payroll Warrants
Please find attached 1 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 Linda W. at ext. 68051 for any questions. Please
route approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant
Thank you.
Replacement Lost Warrant Form 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: pDuplicate 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.
5 OrRACI Yoc,se4j (1), being first sworn, upon oath deposes and says:
Name/Claimant -
On or about December 2, 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 prtibability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance. NUL) ex' reit i!AJ
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 of $ 1 4 1 . 92 .(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) Subs/bed and sworn to before me this ,(0 day of "So,.-v# t 7 2017 .
Y PUBLIC STEVE CANENOUEZ PUBLIC
NOTARY
STATE OF NEVADA
My commission expires: APPT.No.13-11326.1
4-1 3 — ki My APT. MIMES APR,13,201t (seal)
Warrant/Check Number 270000394
(if known) (6)
Original Date of Issue 12/2/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
D For Services or Goods furnished
El Treasurer's refund/payment
LI Other:
AP IP kilQVED 1
Revised April 2015 zog A.R.S. 11-632 & 11-644
DATA JAJA-2
ERK, BOARD OF SUPERVISORS
MARICOPA COUNTY

INTEROFFICE MEMORANDUM
911aricopa County School-Superintendent's Office
TO: CLEM( OE TOE BOARD
FROM: Willie Thompson
SUBJECT: Affidavits
DATE: 1/12/2017
Pase find attached 1 Affidavit/Notice of Craim(s)for Cost warrants for incrusion on
the next avaiCabfe Board agenda
The attached item(s) have 6een researched to ensure that the warrant(s) in
question have not 6een cashed or previous Cy re-issued:
4 The originaC warrant (s) have had a stop payment done.
lf you have any questions, prease contact Willie Thompson at 372-1244 or via e-mair at
mthompson@mcesa.maricopa.gov . Approved Affidavits may 6e routed back, to the
Superintendent of School' Einance Division at 4041 N. Central . Avenue #1200, ( 12 tfi
Efoor) Thankyou.
#59 LAVEEN"EER,GrOSOW ENTERPRISES INC $6396.70
_IA

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El 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.
HR""LII 1111--H11111 C. (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about AUGUST 2, 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/Oeck be issued to him/her in the sum of $ 6,396.70 .( 3)
Signed: _ (4)
Note: Please glitach—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 /q day of 20
,
NOTARY PUBLIC
DORA L. SCHIFFMACHER
My commission expires: Notary Public - Arizona
Maricopa County
Lj/2" • , •'%/ My Comm. Expires Marl, 2018 (seal)
Warrant/Check Number 470024418
(if known) (6)
Original Date of Issue SEPTEMBER 20, 2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
AN 12 nra
WI For Services or Goods furnished 1
111 Treasurer's refund/payment 4,40-TAX
LI Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-6414

CERTIFICATE OF SIGNATORY AUTHORITY
The undersigned Assistant Secretary of FERGUSON ENTERPRISES, INC., a corporation duly organized and existing
under the laws of the State of Virginia (the "Corporation"), hereby certifies that each of the following employee of the
Corporation, individually, is authorized to execute and file on behalf of the Corporation, any affidavit, lien application, lien,
lien waiver, payment application and release of lien necessary to preserve, protect, perfect or remove any encumbrances in or
on real or personal property.
Rene Jimenez wililitriet Credit Mallner
Name Title
The authority referred to above Shall remain in full force and effect until the earliest of (i) July 31, .2018, (ii) written notice of
revocation of such authority is received or (iii). the above referenced individual terminates employment with the Corporation.
Subject to the foregoing, the Corporation's customer relying on this Certificate shall be permitted to treat as authorized all
Documents signed by the above referenced individual in the Corporation's name.
The provisions of this Certificate are in conformity with a resolution adopted by the Board of Directors of the Corporation.
Only the above referenced individuals and all other individuals specifically authorized by the Corporation, may exercise the
authority granted herein.
In witness whereof, I have hereunto subscribed my name and affixed the seal of the Corporation, this 20 day of December,
2016.
COMMONWEALTH OF VIRGINIA
CITY OF NEWPORT NEWS
Sworn to subscribed and acknowledged before me this 20th day of December, 2016, by David N.
Meeker, personally known to me, in his capacity as Assistant Secretary of Ferguson Enterprises, Inc., a
Virginia corporation, on behalf of such corporation. _
idg
Jeiiifer Ann Cloherty
My commission expires 8/31/2020.
THIS CERTIFICATE IS VOID IF ALTERED IN ANY WAY