090716 DUPLICATE WARRANTS 7 - SCHOOLS.PDF

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: 8/11/2016
Please find attached 2 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 602-506-7121 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.
#17 Tolleson El CPR Savers $10688.93
#94 Paloma Arizona Public Service $3656.23
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OAP,0 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 MARICOPA Instruction sheet which is page 2 of this form.
CPR Savers & First Aid Supply,LLC (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about June 22, 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 $ 10,688.93 .(3)
(4)
(5) 1Spbscribed and sworn to before me this day of -6.. ,\IKSA. 20 12 .
A
NOTAR 'PUBLIC DARRYL E COOPER
Notary Public.State of Arizona
Maricopa County
My commission ex ires: My October Commission 09, Expires 2019
ow/ (sea1)
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 460114238
(if known) (6)
Original Date of Issue June 22, 2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
III For Services or Goods furnished
LI 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

OMISavers
M
& FIRST AID SUPPLY ®
August 1' 2016
To whom it may concern,
This letter is to inform you that our employee Maira Alston is an authorized representative
of CPR Savers & First Aid Supply. She has permissions to be the authorized signer for your
enclosed Affidavit / Claim Form regarding our request for a duplicate check/warrant for
our Invoice # 248145 in the amount of $$10,688.93 that you had issued to us but was never
received.
We need this payment re-issued to us as soon as possible as this payment is extremely past
due.
Thank you,
Brandon Taylor
CEO
7904 E. Chaparral Rd. • Ste A110-242 • Scottsdale, AZ 85250
Phone: 1-800-480-1277 • Fax: 1-480-946-2457

4°\\
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 Public Service (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about i0r01- 1.:10 I (e- (clate)(2) a warrant/check was issued to the
above named person/en ity 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 $ 3656.23 .(3)
Signed: ,t'..t- 1-4,1,/ 714 ( /7--Zr. (4)
Ecd and sxorn to before me this 40 day of kik/L.-ti 20 /6.
d'Af I 11.1%111110166. ' _ -
NOTARY PUBLIC Nolarat OFF DIANA IC W. MACIAS MA t
- Arizona
orn iskir(litexpc44 Lrep 001JNTY pii:::
T 2.4. 701:
(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 460105254
(if known) (6)
Original Date of Issue 05/24/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
For Services or Goods furnished
0 Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised lune 2015 A.R.S. 11-632 & 15-999

aps
Station 3209
P0 Box 53933
Phoenix AZ 850723933
Date: 7/21/2016
State of Arizona
County of Maricopa
Ref: Affidavit
Warrant/Check
The following individuals are authorized to sign as a representative of
Arizona Public Service:
Delia McNally
Susie Soto
Sincerely,
APS REVENUE RECOVERY DEPT.