120716 DUPLICATE WARRANTS 8.PDF

INTEROFFICE MEMORANDUM
Ilaricopa County School-Superintendent's Office
TO: CLERK OE D-PE
FROM: Milie Thompson
SUBJECT: Affidavits
DATE: 11/22/2016
Pase find attached 1 Affidavit/Notice of Claim(s)for Cost warrants for indusion on
the next available Ooard agenda
•Ni 'The attached item(s) have 6een researched to ensure that the warrant(s) in
question have not 6een cashed or previous()) re-issued:
'The warrant(s) have had a stop payment done,
If you have any questions, p&tse contact Male Thompson at 372-1244 or via e-mad at
mthompson@mcesa.maricopa.gov . Approved" Affidavits may be routed back to the
Superintendent of School finance (Division at 4041 W. Central Avenue #1200, ( 12 th
Eloor) Thankyou.
#66 ROOSEVELT ADRIENNE C LEFEVRE $ 103 0.44
NOV 23 2016
\IISORS

t-e
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.
Adrienne C. Lefevre (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 24.0 — Z016 (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 $ 1,030.44 .(3)
Signed: (4)
Notary Public State of Arizona
Maricopa County
Ashley Ann Michel
My Commission Expires 07/03/2017
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 160040657
(if known) (6) NO 23 7016
Original Date of Issue 11/26/2015 JATcA___
(if known) (7) ..I"W-• .C.A • ,114/1•06(
Reason for original issue of Warrant/Check (8): , MARIC,OPA BOARD OF COUNTY SUPE9Y16-
ILL/Payroll
El For Services or Goods furnished
VOther: iplotje n eAke,V r-C6eMr,e_ei e-he_d<L• •
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