110216 DUPLICATE WARRANTS 8_REDACTED.PDF

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: October 25, 2016
Re: 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 Wanda at ext. 60409 for any questions. Please route
approved Affidavits back to County Payroll, Suite 220.
Stale Dated Warrant Duplicate Warrant
Thank you.
Replacement Lost Warrant Form 1 02/25/2015

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
•
This application is for: 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.
Mildred Rivera (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09/11/2016 (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/check be issued to him/her inAthe sum of $ 165.00 .(3)
athi
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 sworn to before me this SM day of z &iz 20 ir
1/2/a/044 z--
NO Y PUBLIC Line M. Parkhurst
Notary Public State of New York
Reg.01PA4906979
My commission expires: My CornmissiOn Appointed Explres In Oneida Oct 5 CoufINO/
OCT' (seal)
Warrant/Check Number 22418550
(if known) (6)
Original Date of Issue 09/11/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll APPROVED
LI For Services or Goods furnished
17177
El Treasurer's refund/payment AM'
ti..;-,11v.w,Argsscirdtry-Ar
El Other: K, BOARD OF SUPERVISORS
Revised April 2015

INTEROFFICE MEMORANDUM
Ilaricopa County School -Superintendent's 0
TO: CLERK, OE TOE 00ARD
FROM: Willie 'Thompson
SUBJECT: Affidavits
DATE: 10/25/2016
Pfease find attached 1Affidavit/Notice of Cfaim(s)for Cost -warrants for inc fusion on
the next avada6fe Ooard agenda
The attached item(s) have been researched to ensure that the warrant(s) in
question have not been cashed or previous()) re-issued
The original. warrant(s) have had a stop payment done.
you have any questions, F&Lse contact Mew 'Thompson at 372-1244 or via e-mail at
mthompson@mcesa.maricopa.gov . Approved Affidavits may be routed back to the
Superintendent of School Finance Division at 4041 X CentrafAvenue #1200, ( 12 th
Efoor) Thankyou.
#65 LITTLETON ELE911 COLLEEN - ALLEN - $67.64
if E
OCT 2 5 2016
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
ic

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.
( -) C I ) (1), being first sworn, upon oath deposes and says:
Name7Clai ant
On or about ,\ '(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 $ 62Y- .(3)
1
Signed: (4)
o before me this at day of a-k-hbck- 201CP .
ELBA M. LOZANO
My commission expires: Notary MARICOPA Public- Stale COUNTY of Arizona
tJakm,ba- My November Commission 27, Expires 2017 (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) /&(X)52:-Llic C
Original Date of Issue
(if known) (7) / 1/,,,,,2 t:Z 0 / (el . ..ra wca 5.711 iPTa V 7 1r: Wd
Reason for original issue of Warrant/Check (8):
0 For Services or Goods furnished -CLERK, MARC BOARD FAG OF SUPERVISORS UNTY
0 Other:
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

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: October 25, 2016
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached affidavit for lost warrant to be included on the next available Board
Agenda.
• The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you. IN* to
CZ:3 C >
Re: GREENWOOD MEMORY LAWN MORTUARY
Cf)

Emu1.2,c(
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
page 2 of this form.
Greenwood Memory Lawn Mortuary (1), being first sworn, upon oath deposes and says:
TfErIfb/Claimarr-
On or about 03 -Aug -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/check be issued to him/her in the sum of $ 6,878.36 .(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.
Ind sworn to before me this 2,19f- day of
ROSA ISELA GUERRA
NOTARY PUBUC - ARIZONA
MARICOPA COUNTY
My Commission Expires
August 06,2020
Warrant/Check Number 370001955
(if known) (6)
Original Date of Issue 03-Aug-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
ERK, 80/:\ RD F SUPERVISORS
0 Payroll MARICOPA COUNTY
For Services or Goods furnished VC2016000360, VC2016000407
0 Treasurer's refund/payment
CI Other:
laite
)A-Ialir •

I
r22rtwauN entarg 'Lawn
it I
Mortuary-Cemetery-Crematory-Mausoleum
"Civi fcartity, Mittfing yam's. fa% (mu WU vecva."
October 201 6
To Whom It May Concern,
I, Misuk 5uta Nam, am the Office Manager at, and am authorized to sign for Greenwood
Memory Lawn Mortuary and Cemetery located in rhoenix, Az.
I have signed the attacked affidavit as we did not receive this check for pa yment on burials for
Tomas Olivas, and r clgarclo Cota.
rease re-issue payment as soon as possible as the contract is several months overdue.
best Kegards,
Misuk Suta Nam
2300 W. Van Buren Phoenix, AZ 85009 602-254-8491 • Fax 602-262-0149
DignityMemorial.com