062216 DUPLICATE WARRANTS - 9 - 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: 6/10/2016
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 602-506-7121 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.
#68 Alhambra Dolores Borgetti
RE0.7NED
JUN 13 2016
MARICu:-;-. COUNTY
CLERK BOAI-03 OF SUPERVISORS
I/0 L/vng-A-A -9 6 c)-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.
DOLORES BORGETTI (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 5- --- Z1=' -1(D (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 $ 473 .97 .(3)
Signed: (4)
(5) Subscribe_d_a_pd sworn-totefor e this 6th day of JUNE 20 16 .
OFFICIAL SEAL
My commission expires: MONICA LOPEZ
7 - / v - Notuy MARICOPA Public- State COUNTY ofArizona ! (seal)
My Comm Expires July 14,2018
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 , 1
(if known) (6) I (00 9 Lf 5 1 7 2—
Original Date of Issue
(if known) (7) 5-2 (6, - ( (,
Reason for original issue of Warrant/Check (8):
Payroll
0 For Services or Goods furnished - SUPERVISORS
El 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