060816 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: 5/19/2016
Please find attached 3 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 Sun Life Ins. $4472.60
#60 Roosevelt Lauren Davis $835.82
#60 Higley Pavers LLC $4912.50
MAY 20 2016
MARICOPA C;OUNTY
CLERK BOARD OF SUPERVISORS
/6 LIKPL-C

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.
(1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about g I (date)(2) a warrant/check was issued to the
above named persbn/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 $ 9 t z. .(3)
(4)
(5) Subscribed and sworn to before me this day of tv v,, 1 20 .
n I
NOTARY PUBLIC zOlt. 4 1 OFFICIAL SEAL i
LEAH CRUZ I
My commission expires: Tr, Notary Public - State of Arizona I
/0- I Li,- 1 01 IL.: it• My MARICOPA Cornrn. Expires COUNTY Oct. 26, 2019 ! I (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 (if known) Number (6) Li 6c)-08 LA 9 to v 2 3 7ilili
Original Date of Issue DATA
(if known) (7)
Reason for original issue of Warrant/Check (8): 'MARICOPA COUNTY
LI Payroll
For Services or Goods furnished 1-1 `,-(Z-r)\
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

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Ntm: Amy '‘',.:(1dison
,N1.ay 19, 2016
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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.
Lauren Davis (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 41111)b16- (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
.(3)
Signed: (4)
bscribedl vorn to before me this /7 /41 day of kat/ 20 14°.
Notary Public State of Arizona
Maricopa County
My comTiss7expires: Raquel My Commission Robles Expires 07/03/2017
67/ LI/ 690 7 (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 16-0077388
(if known) (6)
Original Date of Issue 4/28/16
(if known) (7)
Reason,for original issue of Warrant/Check (8):
CPI' Payroll
El For Services or Goods furnished
kl/ Other: ze rVQ-AAr ret.6 ,1) c‘rack
SAPROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999

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.
SUN LIFE ASSURANCE (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about ilafch 3, <20 ap (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 $ 4472.60 .( 3)
Signed: Illat4Lte4t, -71 • -71:4444/).- (4)
/-
(5) Subscribed and sworn to before me this t day of .A7 20 /C .
21 4 zn
OTARY PUBLIC
BARBARA J. KINNEY
My commission expires: NOTARY Punic
_Lido Lj a,-./1 3 020,72./ MY COMMISSION EXPIRES JAN, 31,2021 (seal)
Note; Please attach a copy of the warrant/check if available and/or any othe.r
evidence that a warrant/check was originally issued.
Warrant/Check Number 460078932
(if known) (6)
Original Date of Issue 03/03/2016
(if known) (7) A P 14-4
Reason for original issue of Warrant/Check (8):
LI Payroll
For Services or Goods furnished 3'2016
LI Other: 3'2016
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

Sun
Life Financial®
May 9, 2016
Alhambra Elementary School District
Attn: Rachel Tussing
Accounts Payable
4501 N. 39th Ave
Phoenix, AZ. 85019
RE: Policy Number 067012
Dear Ms Tussing :
As Senior Manager of Client & Technology and Premium Administration Kathleen Tracy has
authority to sign the enclosed affidavit.
Thank you
Joanne Zucco
Operations Coordinator