092116 DUPLICATE WARRANTS - 6.PDF

INTEROFFICE MEMORANDUM
Waricopa County Scfioof Superintendent's Office
TO: CLERK q(191 -E (31)4C10)
FROM: Widfie 'Thompson
SUBJECT: Affidavits
DATE: 9/15/2016
Pcise find attached 3 AffidavitOotice of Craim(s)for Cost warrants for indusion on
the next available Woard agenda
The attached item(s) have been researched to ensure that the warrant(s) in
question have not 6een cashed or previously re-issued
The warrant(s) have had a stop payment done.
If you have any questions, pease contact Mae Thompson at 506.3898 or via e-mad at
mthompson@mcesa.maricopa.gov . Approved Affidavits may be routed 6ack to the
Superintendent of School - Finance (Division at 4041 Y. Central -Avenue #1200, ( 12 tfi
ECoor) Tfiankyou.
#25 LIOERTY ASOAIT $91,361.76
#9 WICKEYOVRG 91171L EV -PERM/SE-S/1/0RX LE51409\1 $1000.00
#201 OrOCUTE VW -IOW KRIS GVY $167.14
RECEIVED
SEP 1 6 2016
MARICORA COUNTY
CLERK BOAF-1D OF SUPERVISORS

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 MAR ICOPA Instruction sheet which is page 2 of this form.
ASBA1T (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 9-15-2015 (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.
laiagoototieiitmluilmrissoistialessiAi sm-Oemitukkases Int)
Signed: 10j,1,-fk A - (4)
KSubscribed and sworn to before me this C-er\-- day ' ---\ervC( 2Ojj
L
NOTARY PUBLIC
My commission expires: g ij Notary CHERYL Public, J. State SMITH of Texas
viagist - My Commission Expires seal)
October 20, 2019
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 460022793 -pp qL5(e,t
(If known) (6)
Original Date of Issue 9-15-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished Payroll deduction check
Other Payroll deduction check
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

Insurance Trust
September 14, 2016
Lisa Marshel
Liberty Elementary District
19818W. Highway 85
Buckeye, AZ 85326
Lisa,
We are in receipt of your request to confirm that ASBAIT has not received Liberty Elementary School
District's payment in the amount of $91,361.76 which was issued on 09/15/15.
Review of the ASBAIT receivables does not reflect receipt of a deposit item in this amount during the
period 09/01/15 through 09/14/16.
Barbara Walker is responsible for the ASBAIT Program accounting and thus has the knowledge and
authority to complete the attached affidavit.
Rick Edwards
BAIT MISSIO
e mission oft e standard for se
its, and a d their dependent

Millie Thompson - MCESAX
From: Marshel, Lisa <LMarshel@liberty.k12.az.us >
Sent: Wednesday, September 14, 2016 1:02 PM
To: Denise Weihe - MCESAX; Millie Thompson - MCESAX
Cc: FinanceDesk; Baysinger, Kelley
Subject: FW: Liberty group 13685
Attachments: ASBAIT - Letter to Liberty [SD 09-14-16.pdf; Liberty Check Log 09-01-15 thru
09-14-16.pdf
Hi Denise and Millie,
I am forwarding the letter authorizing Barbara Walker to confirm that the lost warrant was never received. Additionally,
she has attached the check log which indicates that Warrant #460022793 in the amount of $91,361.76 was not
deposited.
Thank you so much for all your assistance.
Lisa
LISA MARSHELI Payroll Specialist
Liberty Elementary School District No. 25
Direct (623) 474-6615 FAX (623) 474-6629
Email: Imarshel@liberty.k12.az.us
www.liberty.k12.az.us (Building World Class Schools
From: Barbara Walker [mailto:Barbara©edwardsrisk.com ]
Sent: Wednesday, September 14, 2016 12:54 PM
To: Marshel, Lisa; 'Larson, Jana'; Irschwenn@azschoolplans.com '
Cc: Baysinger, Kelley
Subject: RE: Liberty group 13685
Good Afternoon Lisa,
As per your request, please see the attached confirmation letter. I have also included a check log of all items received
for Liberty [SD in case there are other items for which you would like to confirm receipt.
Please let me know if you have any questions.
Thank you,
Ri5.2K Management, inc.
Barbara Walker
Edwards Risk Management, Inc.
1004 Marble Heights Dr.
Marble Falls, TX 78654
1

2:30 PM Arizona School Boards Association Insurance Trust
Transaction Detail By Account
09/14/16
Accrual Basis September 1, 2016 through September 14, 2016
Type Date Num Name Memo Class Credit
Contributions
Deposit 09/04/2015 460018356 Liberty Elementary School District 09/04/15 Lockbox Liberty:15 85,626.73
Deposit 10/05/2015 460027677 Liberty Elementary School District 10/05/15 Lockbox Llberty:15 87,992.65
Deposit 10/05/2015 1124 Liberty Elementary School District 10/05/15 Lockbox Liberty:15 9,217.00
Deposit 10/16/2015 460032333 Liberty Elementary School District 10/16/2015 Lockbox Liberty:15 89,910.61
Deposit 11/02/2015 460036876 Liberty Elementary School District 11/02/15 Lockbox Liberty:15 69,970.60
Deposit 11/04/2015 460017394 Liberty Elementary School District 11/03/15 Lockbox Liberty:15 655,000.00
Deposit 11/12/2015 460041052 Liberty Elementary School District 11/12/15 Lockbox Llberty:15 88,374.28
Deposit 11/27/2015 460045702 Liberty Elementary School District 11/27/15 Lockbox Liberty:16 89,076.23
Deposit 12/15/2015 480049478 Liberty Elementary School District 12/15/15 Lockbox Liberty:15 88,392.01
Deposit 12/24/2015 460057260 Liberty Elementary School District 12/24/15 Lockbox Liberty:15 89,568.02
Deposit 01/11/2016 460058772 Liberty Elementary School District 1/11/16 Lockbox Liberty:15 68,708.81
Deposit 01/25/2016 460063322 Liberty Elementary School District 01/25/2016 Lockbox Liberty:15 68,860.52
Deposit 02/05/2016 460087701 Liberty Elementary School District 02/05/16 Lockbox Liberty:15 87,617.45
Deposit 02/08/2016 1126 Liberty Elementary School District 02108/16 Lockbox Liberty:15 8,634.00
Deposit 02/22/2016 460072991 Liberty Elementary Schoo District 02/22116 Lockbox Liberty.15 88,648.72
Deposit 03/14/2016 460077054 Liberty Elementary Schoo' District 03/14/16 Lockbox Liberty15 89,075.32
Deposit 03/21/2016 480081683 Liberty Elementary Schoo District 03/21/16 Lockbox Liberty :15 90,902.35
Deposit 03/31/2016 460085707 Liberty Elementary Schou District 03/31/16 Loc,kbox Liberty:15 69,623.67
Deposit 04/14/2016 460089979 Liberty Elementary Schoo District 04/14/2016 lockbox Liberty:15 89,885.07
Deposit 04/29/2016 460094713 Liberty Elementary Schoo District 04/29/2016 Lockbox Liberty:15 89,840.96
Deposit 05/13/2016 1128 Liberty Elementary Schoo District 05/13/2016 Lockbox Liberty:15 6,369.00
Deposit 05/13/2016 460099104 Liberty Elementary Schoo District 05/13/2016 Lockbox Liberty:15 89,482.26
Deposit 05/31/2016 460103924 Liberty Elementary Soho° District 05/31/2016 Lockbox Liberty:15 88,487.07
Deposit 06/16/2016 460108136 Liberty Elementary Schoo District 08/16/2016 Lockbox Liberty:15 770.73
Deposit 06/16/2018 460108128 Liberty Elementary Schoo District 06/16/2016 Lockbox Liberty:15 288.21
General Journal 07/01/2016 184 Liberty Elementary Schoo District July 2016 Premium Invoice Liberty:16 159,027.70
General Journal 08/01/2016 190 Liberty Elementary Schoo District August 2010 Premium Invoice Liberty:16 157,739.70 . .
Total Contributions 2,607,089.87
TOTAL 2,607,089.67
Page 1

Phone - 830.693.2728 ext. 225
Fax - 830.693.2729
barbaraedwardsrisk.com
www.edwardsrisk.com
Please consider the environment before printing this e-mail.
CONFIDENTIALITY NOTICE: This e-mail is intended solely for the person or entity to which it is addressed and may contain confidential and/or
privileged information. Any review, dissemination, copying, printing, or other use of this e-mail by persons or entities other than the addressee is
prohibited. If you have received this e-mail in error, please contact the sender immediately and delete the material from your computer.
From: Marshel, Lisa [mailto:LMarshel@liberty.k12.az.us]
Sent: Wednesday, September 14, 2016 1:57 PM
To: 'Larson, Jana'; 'rschwenn@azschoolplans.com '; Barbara Walker
Cc: Baysinger, Kelley
Subject: FW: Liberty group 13685
Importance: High
Hello All,
Jana and Barbara — I have left you both rather lengthy voice messages.
Unfortunately, we are still working on the void and re-issue of Warrant #460022793 in the amount of $91,361.76. After
receiving the Affidavit from Barbara Walker confirming that the check had never been received or cashed, we
immediately forwarded that form to MCESA. Yesterday, we called MCESA to check on the progress and were informed
that there is an additional requirement.
Because the check was issued to a corporation rather than an individual, the county office requires a letter on ASBAIT
letterhead stating that Barbara Walker is an authorized representative for ASBAIT and has the authority to sign the
Affidavit. Alternatively, I believe that a letter on Edwards Risk Management letterhead stating their relationship with
ASBAIT and that Ms. Walker has the authority to confirm the lost warrant would suffice.
At this point, we are rather desperate to get the letter. Our deadline is 9/15/16 to get the Affidavit and Letter submitted
to the county office or we lose the opportunity to have this check re-issued and therefore, lose these funds.
Any help you can provide would be greatly appreciated.
Thank you!
Lisa
LISA MARSHELI Payroll Specialist
Liberty Elementary School District No. 25
Direct (623) 474-66151 FAX (623) 474-6629
Email: Imarshel@liberty.k12.az.us
www.liberty.k12.az.us I Building World Class Schools
From: Marshel, Lisa
Sent: Tuesday, September 13, 2016 12:34 PM
To: 'Barbara Walker'
Cc: Baysinger, Kelley
Subject: FW: Liberty group 13685
Importance: High
Hello Barbara,
2

I am so sorry for the inconvenience but MCESA (Ma ricopa County Education Service Agency) who is processing the void
and re-issue on this check is requesting a letter from you on ASBAIT letterhead stating that you are an authorized
representative and have the authority to sign the Affidavit which you sent last week stating that warrant.
If it is at all possible, I would greatly appreciate it if you could e-mail or fax this to me today since we only have a couple
of days to get this check re-issued at this point.
Thank you so much,
Lisa
LISA MARSHEL I Payroll Specialist
Liberty Elementary School District No. 25
Direct (623) 474-66151 FAX (623) 474-6629
Email: Imarshel@liberty.k12.az.us
www.liberty.k12.az.us 1Building World Class Schools
From: Barbara Walker [mailto:Barbara@edwardsrisk.com]
Sent: Friday, September 09, 2016 1:58 PM
To: Marshel, Lisa
Cc: 'Larson, Jana'; 'rschwenn@azschoolplans.com '
Subject: RE: Liberty group 13685
Good Afternoon Lisa,
I hope this finds you doing well.
As per our discussion, I have drawn a line through the second paragraph and have signed and notarized the affidavit.
Please let me know if you have questions. Have a nice weekend!
Risk Management, , r1c-.
Barbara Walker
Edwards Risk Management, Inc.
1004 Marble Heights Dr.
Marble Falls, TX 78654
Phone - 830.693.2728 ext. 225
Fax - 830.693.2729
barbaraedwardsrisk.com
www.edwardsrisk.com
Please consider the environment before printing this e-mail.
CONFIDENTIALITY NOTICE: This e-mail is intended solely for the person or entity to which it is addressed and may contain confidential and/or
privileged information. Any review, dissemination, copying, printing, or other use of this e-mail by persons or entities other than the addressee is
prohibited. If you have received this e-mail in error, please contact the sender immediately and delete the material from your computer.
From: Larson, Jana [mailto:Janalarson@meritain.corn]
Sent: Tuesday, September 06, 2016 6:13 PM
To: Barbara Walker
Subject: RE: Liberty group 13685
3

Thank you Barbara,
I do not see the check that is in question. Are comfortable signing and having notarized and then return to Lisa Marshel
the attached that she forwarded to me so that she can have the check re-issued?
If I should go to someone else for this please let me know. I don't remember a request like this in the past.
Thank you so much!
Jana Larson
Account Manager
lana.larson@meritain.com
602-789-0812 Direct
716-345-6355 Cell
888-828-4926 Toll Free
716-541-6663 Fax
18444 N. 25th Avenue #410
Phoenix, AZ 85023
Our Values: Integrity, Excellence, Inspiration, Caring
I HAI\
HEALTH
From: Barbara Walker [mailto:Barbara@edwardsrisk.com]
Sent: Tuesday, September 06, 2016 7:04 PM
To: Larson, Jana
Subject: RE: Liberty group 13685
Jana,
Below is a list of payments received from Liberty since 09/01/15:
4

Deposit 0910412015 460018356 Liberty Elementary School District 09/04/15 Lockbox Liberty:15 85,626.73
Deposit 10/0512015 460027677 Liberty Elementary School District 10/05115 Lockbox Liberty:15 87,992.65
Deposit 10/05/2015 1124 Liberty Elementary School District 10105115 Lockbox Liberty:15 9,217.00
Deposit 10/16/2015 460032333 Liberty Elementary School District 10116/2015 Lockbox Liberty:15 89,910.61
Deposit 11/02;2015 460036876 Liberty Elementary School District '11;02)15 Lockbox Liberty:15 69,970.60
Deposit 1110412015 460017394 Liberty Elementary School District 11/03/15 Lockbox Liberty:15 655,000.00
Deposit 11/12;2015 460041052 Liberty Elementary School District 11/12/15 Lockbox Liberty:15 88,374.28
Deposit 11127/2015 460045702 Liberty Elementary School District 11/27/15 Lockbox Liberty:15 89,076.23
Deposit .12/15/2015 460049478 Liberty Elementary School District 12/15;15 Lockbox Liberty:15 88,392,01
Deposit 12/24/2015 460057260 Liberty Elementary School District 12/24115 Lockbox Liberty: '15 89,568.02
Deposit 01111/2016 460058772 Liberty Elementary School District 1/11116 Lockbox Liberty:15 68,708.81
Deposit 01/25/2016 460063322 Liberty Elementary School District 01125)2016 Lockbox Liberty:15 68,860.52
Deposit 02/05/2016 460067701 Liberty Elementary School District 02105116 Lockbox Liberty: '15 87,617.45
Deposit 02108/2016 1126 Liberty Elementary School District 02/08116 Lockbox Liberty:15 8,634.00
Deposit 02/22/2016 460072991 Liberty Elementary School District 02122)16 Lockbox Liberty:15 68,648.72
Deposit 0311412016 460077054 Liberty Elementary School District 03,1 4/16 Lo ckbox Liberty:15 89,075.32
Deposit 03121/2016 460081683 Liberty Elementary School District 03121/16 Lockbox Liberty:15 90,902.35
Deposit 03131/2016 460035707 Liberty Elementary School District 03131/16 Lockbox Liberty:15 69,623.67
Deposit 04/14/2016 460089979 Liberty Elementary School District 04114/2016 Lockbox Liberty:15 89,885.07
Deposit 04;29/2016 460094713 Liberty Elementary School District 04/29/2016 Lockbox Liberty:15 89,840.96
Deposit 0511312016 1128 Liberty Elementary School District 05113/2016 Lockbox Liberty:15 6,369.00
Deposit 05/13/2016 460099104 Liberty Elementary. School District 05113/2016 Lockbox Liberty:15 89,482.26
Deposit 05131/2016 460103924 Liberty Elementary School District 05131;2016 Lockbox Liberty:15 88,487.07
Deposit 06/16/2016 460108136 Liberty Elementary School District 06116/2016 Lockbox Liberty:15 770.73
Deposit 06/16/2016 460108128 Liberty Elementary School District 06/1612016 Lockbox Lberty:15 288.21
Risk Management, inc.
Barbara Walker
Edwards Risk Management, Inc.
1004 Marble Heights Dr.
Marble Falls, TX 78654
Phone - 830.693.2728 ext. 225
Fax - 830.693.2729
barbaraedwardsrisk.com
vvvvvv.edwardsrisk.com
Please consider the environment before printing this e-mail.
CONFIDENTIALITY NOTICE: This e-mail is intended solely for the person or entity to which it is addressed and may contain confidential and/or
privileged information. Any review, dissemination, copying, printing, or other use of this e-mail by persons or entities other than the addressee is
prohibited. If you have received this e-mail in error, please contact the sender immediately and delete the material from your computer.
From: Larson, Jana [mailto:Janalarson@meritain.com]
Sent: Tuesday, September 06, 2016 5:26 PM
To: Barbara Walker
Subject: Liberty group 13685
5

Hello Barbara,
I hope you have had a wonderful long weekend!
I received a phone call from Lisa Marshel at Liberty. She states that it was recently brought to her attention that a check
they sent dated September 15t h, 2015 in the amount of $91,361.76 has not cleared. Do you show that this was ever
received? If not, could you please complete the attached and send it to Lisa Marshel at the following:
LISA MARSHEL1 Payroll Specialist
Liberty Elementary School District No. 25 Direct (623) 474-66151 FAX (623) 474-6629
Email: Imarshel@liberty.k12.az.us
Lisa is under a bit of a time crunch it sounds like as she needs to request this to be reissued before a year has past.
Please let me know if you have any questions.
Thank you so much!
Jana Larson
Account Manager
jana.larson@meritain.com
602-789-0812 Direct
716-345-6355 Cell
888-828-4926 Toll Free
716-541-6663 Fax
18444 N. 25th Avenue #410
Phoenix, AZ 85023
Our Values: Integrity, Excellence, Inspiration, Caring
ITA N
HEALTH
Note: The information contained in this message may be privileged and confidential and protected from disclosure. If the reader of this message is not the intended
recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or
copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by replying to the message and
deleting it from your computer.
Note: The information contained in this message may be privileged and confidential and protected from disclosure. If the reader of this message is not the intended
recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or
copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by replying to the message and
deleting it from your computer.
6

WICKENBURG UNIFIED SCHOOL DISTRICT NO. 9
40 W. Yavapai, Wickenburg AZ 85390 314
Phone (928) 668-5350 Fax (928) 668-5390
CHAMPIONS
— FOR —
CHILDREN
AFFIDAVIT
Lernal dba. TY) Kt, Eilf being first duly sworn, upon oath deposes and says:
That on the 40 day • ofJ /Ant 20/10; he presented to Wickenburg Unified School District #9
Maricopa County, for payment, a claim for services rendered or supplies furnished during the
month of said claim being the sum of 441e 41011isard
Dollars ($ (1060.-- „,0 ) in payment of which the Superintendent of Schools caused Warrant #
ttivo D 3 -710 to be issued onJuite, , 20 , drawn on the 00 I fund of
Wickenburg Unified School District #9 of Maricopa County, Arizona.
Affiant further says that although he was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost.
Wherefore, affiant prays that the Board of Supervisors order and the Superintendent of schools
issue to him a duplicate of said Warrant # 40/ 01770in the sum of $ 1 )000 e °
IS;
Signature
Marg. Ltp-io
Subscifilied and sworn before me this / day of
0:20(q
Notary Signature Commission Expiration Date
DAWN M. BENDER
Navy Public- State of kixone
MARICOPA COUNTY
My Commission Expires
November 4,2019
Following Notary approval please return original affidavit to: APPIVU\tik•iP
Wickenburg Unified School District
Accounts Payable P 16 2015
40 W. Yavapai Street DAT,
Wickenburg, AZ 85390
CLERK. BOARD OF SUPERVISORS
MARICOPA (-2,CL;NTY

IVIKL, Enterprises
Water! Wastewater Consultation a Operation
State Certification #09441
• • *
PO Box 1937. Wickenburg, AZ 85358
Mobile 928-231-2606 Email: nomelmk@yahoo.com
9/7/2016
To whom it may concern;
Ma, Enterprises is sole proprietorship business entity owned and operated by Mark K Lemon.
Mark K Lemon, A MKL, Enterprises

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.
KRIS GUY (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 8/23/2016 (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 $ 167.14 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this i day of 20 11P .
0
NOTARY PUBLIC LESLIE DOUD
Notary Public - Arizona
My commission expires: /100 , ,(:)1 fr My Comm. Maricopa Expires County Nov 14, 2017
8/23/2016 (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 470014654
(if known) (6)
Original Date of Issue 08/23/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
0 For Services or Goods furnished REIMBURSEMENT
Other: REIMBURSEMENT
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

mismomnouxammosomoniammunountmumenminnannammunno, :1111S. D_OCAIME 0,141:AIN entinuommuommunamsmelnummomnrunommunn
SCHOOL' EXPENSE WARRANT JPMorgan Chase Bank, N.A. 47001465471
Phoenix, AZ
TREASURER OF MARICOPA COUNTY
PHOENIX, ARIZONA 91 -2/1 221 DATE CONTROL NO.
TRIS WARRANT DRAWS INTEREST FROM DATE MARKED ''INSUFFICIENT FUNDS'
INTEREST STOPS ON DATE FUNDS AVAILABLE. (SEC 11-636. AR51956)
Buckeye Union High School District #201 WARRANT AMOUNT
PAY
***One Hundred Sixty Seven and 141100*** Dollars $167.14
VOID AFTER 365 DAYS
TO
THE GUY, KRIS tfC?)
ORDER 22942 W. HOPI ST. t L y
OF BUCKEYE, AZ 85326 Dr. Donald Covey
Superintendent of SchttlaT§HORIZED SIGNATURES
11.11700 ili6SLio 2 2 L000 2ti i: 970 11391193v
MARICOPA COUNTY SCHOOLS • PHOENIX, ARIZONA 08/23/2016 Check: 201616351 EXPENSE
AP Run Date 08-19-16 470014654
GUY, KRIS I 08/23/2016 I
Payee Check Date
Account Number PO Number Invoice Amount
596270221365802017160000 170323 ACTEAZ 2016 167.14
VOUCHER: 8013 TOTAL: $167.14
HARLAND CLARKE M22692 60126026

SIGNATURE OFFICE SIGNATURE TITLE NAME I
USE OF OF CERTIFY 0 DATE:
FOR ONLY: OF REQUESTOR REQUESTOR THAT ORIGINAL Purchased Request
APPROVAL REQUESTOR THESE RECEIPTS order Request
OF 08/15/16
CHARGES ARE number reimbursement/payment BUCKEYE
REMIBURSEMENT: ARE ATTACHED obtained reimbursement REQUEST
DUE (if to prior the for the in SOURCE UNION
Kristina AND applicable) purchase following amount OF FOR
Guy PAYABLE : : $: of FUNDS: HIGH
AND 170323 and Meals $167.14
THAT REIMBURSEMENT SCHOOL
PRIOR mileage DISTRICT
DATE: CLAIM FUNDS DISTRICT
HAS
NOT
BEEN
MADE.