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INTEROFFICE MEMORANDUM Ilaricopa County Education Service Agency TO: Crerkof the Ooard FROM: Ersa Perez SUBJECT: Affidavits — Wplacement ofLost/StalTe Warrants DATE: 12/7/2015 Pctse find attached Affidavit/Notice of Cfaim(s)for Cost warrants for incrusion on the next avaitabfe Ooard agenda. The attached item(s) have 6een researched to ensure that the warrant(s) in question have not been cashed or previously re-issued The original warrant (s) have had a stop payment done. If you have any questions, please contact Earl Perez at (602) 506-3533 or via e-mail at garnishments@mcesa.maricopa.gov . Approved Affidavits may 6e routed back to the 914aricopa County Education Service Agency at 4041 9V: Central Avenue #1200, (12th Efoor) Thankyou. Fund 781 CYNTHIA 1(ENT $1343.91 tfv-LA ECL DEC 08 20 5 MARICOPA COUNTY CLERK BOARD OF SUPERVISORS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: U Duplicate or 0 Stale-Dated (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. CYNTHIA KENT (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 26TH OF NOVEMBER 2015 ( 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 $ 1343.91 .(3) S. Signed: (2j, (4) Note: Rease attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5)5U-bscribed and sworn to before me this day of 2O±5 . NOTARY PUBLIC DEBORAH CARBAJAL LOPEZ My commission expires: Notary Public- State of Adzona &e: Ze:77•,-1' MARICOPA COUNTY (seal) My Commission Expires Crinter Z. %ma Warrant/Check Number 160041880 (if known) (6) Original Date of Issue 11/26/15 (if known) (7) Reason for original issue of Warrant/Check (8): El Payroll LI For Services or Goods furnished -- • — LI Treasurer's refund/payment LI Other: S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644