050416 DUPLICATE WARRANTS - 8.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: 4/21/2016
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.
#216 Agua Fria Arisa Moser $36.23
#47 Arlington Hollis Larson $264.00

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.
ARISA MOSER (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about -)-j-1/\5 (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 $ 36 .23 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this /5- day of /72/<) /L 20 /6, .
NOTARY PUBLIC
My commission expires:
7- 2,- Zo (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 150077388
(if known) (6)
Original Date of Issue 05/07/2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
Payroll
fl Fo,r ccriircc ,o,r k,p7. I.s!Nec.1, E.ERK. BOARD OF SUPERVISORS
mAr--rICOrA COUNTY
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

Affidavit
STATE OF ARIZONA APPROVED
APR 24, 2016
DATE
COUNTY OF MARICOPA )
K, BOARD OF SUPERVISORS
MARICOPA COUNTY
/468/6 LdArsern-- being first duly sworn, upon oath deposes and says:
That on the 1(,, day of r-thr(14111) , 20)0 he presented to the
a . I
of Maricopa County, for payment, a claim for services
rendered or supplies furnished during the month of , said claim being
r:0666 (s_cp/ao
in the sum o Dollars
in payment of which the Superintendent of Schools caused his/her Warrant No. WO/7V 73
to be issued on IbrLLaf(Jf Iii , 20 , drawn on the ,22d Fund of
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 number 4/007.9(/ 73 in the sum of
$
Subscribed and sworn before me this
vet-4 OFFICIAL SEAL
Notas MELANIE y Public - FINCHUI,..,1 State of Artzeivi Notary Pilblit
1,:lIGOPA AR COUNTY
ly Comm. Evirea Aura 1,2019
My Commission Expires
Following approval please return this affidavit to the Maricopa County School Superintendent's Office.
HAVVorkkAffidavit.doc 07/14/05