101916 DUPLICATE WARRANTS 2_REDACTED.PDF

RECEIVED
MARICOPA COUNTY OCT 0 6 2016
Department of Finance MARICOPA COUNTY
301 West Jefferson, Ste 960 CLERK BOARD OF SUPERVISORS
Phoenix, Arizona 85003 ;/0 LLe Of)
INTEROFFICE MEMORANDUM
Date: October 6, 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.
-71 C-)
Cr)
Re: BANNER OCCUPATIONAL HEALTH CLINICS

Application for a Duplicate or Stale-Dated RE waCrraEZECDheck
APR 252016
RISK MANAGEMENT
This application is for: • Duplicate or El 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.
Banner Occupational Health Ser (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 27-Jan -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 $ 1,888.00 .(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 sworn to before me this c..49 - 7/1 day of
NOTARY PUBLIC JANICE L. PADDEN
NOTARY PUBLIC - ARIZONA
MARICOPA COUNTY
My commission expires: My Commission Expires
c/7 May 12, 2017 (seal)
Warrant/Check Number 00360017088
(if known) (6)
Original Date of Issue 27-Jan-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
For Services or Goods furnished Workers' Compensation
0 Treasurer's refund/payment
0 Other:
dADbF SjPnVISORS
MARICOPA COUNTY

Banner
Occupational
Health Clinics
Banner Occupational Health Clinics
525 W Brown Rd 8th FL NW
Mesa, AZ 85201
To whom it may concern:
Dioceline Lascano Zambrano has the authorization to act on behalf of Banner Occupational Health for
the purpose of a reissue in payment.
Thank you,
Sabrina Harbin
PFS Supv
Banner Occupational Health Clinics

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: 10/6/2016
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.
#90 Saddle Mountain Ashton Tiffany $75.00
6
CLERK -L VISORS
0

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.
ame/Claimant S-A -61 (1), being first sworn, upon oath deposes and says:
On or about ,,L14 C;4 (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, gr: 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 $ .00 .(3)
Signed: (4)
7
Subscribed and and worn to before me this Zi day of -5e,0-c-/AAY->cx 20_
NoTARY PUBLIC
My commission expires: Notary DIVIANA Public,State MATUSZEWSKI of Arizona
061( 01 K My Commission Maricopa County Expires (seal)
May 08, 2018
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) 4)a-AkoW9 —7(- 0 -s--525
Original Date of Issue
(if known) (7) --1 fi-Ci I 1-c<9 _ __
Reason for original issue of Warrant/Check (8):
0 Payroll
10-1 -or Services or Goods furnished
0 Other:
Revised S:\PROCESSESMarrants June 2015 - Duplicate or Stzle\02 Forms\Schools\Schools-Warrants Checks notice of clalm.doc
A.R.S. 11-632 & 15-999

ASHTON ftTIFFANY
SERIOUS ABOUT RISK MANAGEMENT
September 22, 2016
RE: DUPLICATE WARRANT/CHECK
To whom it may concern:
This letter is a letter authorizing Kathleen Williams to sign on behalf of Ashton Tiffany, LLC for
the warrant/check documents required.
Norman Hall
General Counsel
333 East Osborn Road Tel 602.257.9119 www.ashtontiffany.com
Phoenix AZ 85012 Fax 602.257.5117

INTEROFFICE MEMORANDUM
Waricopa County School - Superintendent's Office
TO: CLEWK OE WE 00AWD
FROM: Willie Thompson
SUBJECT: Affidavits
DATE: 10/6/2016
Prease find attached 1 AffidavitOotice of CCaim(s)for Cost warrants for incrusion on
the next avaiCabCe Ooard agenda
The attached item(s) have been researched to ensure that the warrant(s) in
question have not been cashed or previous Cy re-issued
The originar warrant(s) have had a stop payment done.
If you have any questions, pThase contact Millie Thompson at 372-1244 or via e-mair 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
Efoor) Thankyou.
#68 ALWAgl1OR3 ARIZONA ELECTRIC SUPPLY $80.04
Ofis
Avv.,,JU

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.
ARIZONA ELECTRIC SUPPLY (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 03/29/2016 (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 $ 80.04 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this day of 20 \ .
NOTARY PU IC NANCY L. JOHNSON
Notary Public - Arizona
My commission expires: My Maricopa Commission County Expires
August 9, 2018 (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 460086633
(if known) (6)
Original Date of Issue 03/29/2016
(if known) (7)
0 6 016
Reason for original issue of Warrant/Check (8):
Payroll
'"CrERK. BOARD OF SUPERVISORS
Ell For Services or Goods furnished 5917-688733 MARICOPA
Other: 5917-688733
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claindoc A.M. 11-632& 15-999
Revised June 2015

EED CONSOLIDATED ELECTRICAL DISTRIBUTORS, INC.
DIVISION CREDIT OFFICE P.O. BOX 15367
SCOTTSDALE, AZ 85267
ALSO DOING BUSINESS AS
ARIZONA ELECTRIC SUPPLY SCOTTSDALE AIRPARK
CAPITAL ELECTRIC SUPPLY 15230 N. 75TH ST, SUITE 2020
SCOTTSDALE, AZ 85260
DAHL ELECTRIC SUPPLY
TRIANGLE ELECTRIC SUPPLY TELEPHONE: (480) 966-5227
VEGAS ELECTRIC SUPPLY FAX: (480) 966-7886
TOLL-FREE: (800) 653-5227
September 28, 2016
ALHAM BRA SCHOOL DISTRICT #68
4510 NORTH 37TH AVENUE
PHOENIX AZ 85019
Dear Rachel Tussing,
Chris Besenhoffer is qualified and authorized to sign lost check affidavits on behalf of Consolidated
Electrical Distributors et.
Please contact me should you need additional information.
Sincerely,
/ 1
Tiff . :egl

Maricopa County
Human Resources
Memo
To: Fran McCarroll, Clerk of the Board
From: Wanda Childers
Date: October 5, 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 2-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.
•I•.1116
Ack< 9e. 1_61- Q-ed 42 5 (1), being first sworn, upon oath deposes Oticl
Name/Claiman
On or about al-ollet- 14 i `Z-016 (date )(2) a warrant/check was issue-a '4 to, —I the
above named person/entity in the amount as stated below. Such warrant/necle—was
either never received or was subsequently inadvertently lost or destroyed arid thq is
no reasonable probability of its being found or presented for payment, or tct-), waa-not
presented for payment within one year after the date of issuance. m
r‘y
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 $ ots1 . .(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 sworn to before me this 4/ day of 00# c e• 20 a.
NOTARY PUBLIC
MARC A LYLES
My commission expires: Notary Public. Stale of MIAMI
TAARCOPA COUNTY
V-, .2, a/ te. My Commission Expires April 15. 2010 (seal)
Warrant/Check Number
(if known) (6) cpoaaLi 2.14,10-
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8): APPROVED
)21 Payroll DAT OTT 0 6 L16
O For Services or Goods furnished •II•-•••• 'LA 5.7"
Z. • AHD OF SUPERVISORS
O Treasurer's refund/payment MARICOPA COUNTY
O Other:
Revised April 2015 A.R.S. 11-632 & 11-644