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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: 2/23/2016 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. #216 Agua Fria McKenzie Kueker $40.25 RECEIVED FEB 2 4 2016 AAAR;cor,/,,,, UNTY CLERK BOARD OF //o 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. MCKENZIE KUEKER (1), being first sworn, upon oath deposes and says: Name/Claimant On or about FEB 3, 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 $ 40.25 .(3) Signed: (4) (5) Subscribiell and swo o before me this (--) day of \, 20 NOTARY PUBLIC ANNA M. GUERRERO *tag Public - State ofArians My commission expires: My Comrnission MARICOPA Expires COUNTY Feb. 24, 2619 FEB 3,2016 (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 160057967 (if known) (6) Original Date of Issue JAN 28, 2016 (if known) (7) At_ Reason for original issue of Warrant/Check (8): 2016. Payroll LII For Services or Goods furnished 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