120716 DUPLICATE WARRANTS 4.PDF

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: 11/15/2016
Please find attached 1 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.
#44 Avondale Cochise Petroleum $1462.33

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.
(1), being first sworn, upon oath deposes and says:
On or about , „,v • (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
warranti-e eck be is?4,0 to him/her in the sum of $ \ /-)• • ) .(3)
Signe (4)
(5) Subscribed and sworn to before me this ___day of 1400emba-20 I (# .
6k(
NOTARY PUBLIC REBECCA A. MAIFIELD
War/ Public - State of Arizona
MARICOPA COUNTY
My commisibn expires: My February Commission 23, 2020 Expires
(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
(if known) (6) i-kr, b 0 6 (A-61.p CA'
Original Date of Issue (a 1 (b (
(if known) (7) IL Sillk TII1 VS OW 'ar ea, Iin
Reason for original issue of Warrant/Check (8): NO1A 1 5 2016
O Payroll
II For Services or Goods furnished
O Other:
SAPROCESSES\Warrants - Duplicate or Stale\02 Fornns\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999

Certified
WBENC COCHISE "PR
LWomen's Business Enterprise)
333 N. Black Canyon Hwy., Phoenix, AZ 85009-4518 • Phone: 602-272-0911
To: Avondale Elementary School District
Attn: Accounts Payable Department
October 28, 2016
Please be advised, Rita Sotelo is our head Accounts Receivable for Cochise Companies and she is authorized to sign
the Affidavit Claim form that is required to have a check void and reissued to the company. Please let me know if you
have any further questions by calling 602-272-0911.
Apryl Erekson
Cochlse Contractors, Inc.
Phone: Fax: 602-272-0911 602-242-1580 cc Cochlse Phone: 602-242-8427 Petroleum Equipment Co, Inc.
License #s: B01073119; Fax: 602-943-6855
L05071379; L11219846 License #: L05122847