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INTEROFFICE MEMORANDUM Ilaricopa County Education Service Agency TO: Clerkof the Board FROM: CARRIE GUNDERSON SUBJECT: Affidavits — Replacement of Lost /Stare Warrants DATE: 10/28/2016 Pase find attached Affidavit/Notice of Claim(s)for lost warrants for inclusion on the next availa6le Board agenda. -\1 The attached item(s) have been researched to ensure that the warrant(s) in question have not been cashed or previously re-issued The warrant(s) have had a stop payment done. If you have any questions, p lease contact Carrie Gunderson at (602) 372-4833 or via e- mail at garnis fiments@mcesa.maricopa.gov . Approved Affidavits may be routed back, to the gilaricopa County Education Service Agency at 4041 X. CentrafAvenue #1200, (12th Efoor) Thankyou. Eund 781 160091706 6/8/16 for $ 1630.54 Regina Curiale --110 m Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form • This application is for: Duplicate or U 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. ink Uritz.le. (1), being first sworn, upon oath deposes and says: &Claimant On or about gi I (c? (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 $ I lo30 .(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)Subscribed and WOFR-4-0_ Eefore me this (R ) day of Datbhffir 20 ILO. )6UX0 NOTARY PUBLIC 1 RUTH LETOFSKY Notary Public- Staled Arizona My coirimi sion _expires: My MARICOPA Commission COUNTY Expires 1-1- cC4bc;k.) March 4,2020 (seal) Warrant/Check Number cc° (if known) (6) I 40009 Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): it id' -V It 0 V E Payroll DATE, OCT 0\1 2016 0 For Services or Goods furnished 0 Treasurer's refund/payment K, BOARD 0 SUP 7ishPs MARICOPA COUNTv g Other: S:\PROCESSES\Warrants - Duplicate or Stale \02 Forms\Warrants Checks notice of claim - Copy.doc A.R.S. 11-632 & 11-644 Revised April 2015