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INTEROFFICE MEMORANDUM Maricopa County School-Superintendent's 0, TO: CLERK OE TOE WARD FROM: Willie Thompson SUBJECT: Affidavits DATE: 12/18/2015 Pase find attached _2 Affidavit/Arotice of Craim(s)for Cost warrants for indusion on the next avaiCa6Ce Ooard agenda The attached item(s) have been researched to ensure that the warrant(s) in question have not been cashed or previousCy re-issued The original-warrant(s) have had a stop payment done. If you have any questions, r&tse contact Thompson at 506.3898 or via e-mail - at mthompson@mcesa.maricopa.gov . Approved Affidavits may be routed back to the Superintendent of School- Finance (Division at 4041 X. Central- Avenue #1200, ( 12 th Coor) Thankyou. #45 TOWLER DAWN - EITZ1-frOc7r $ 164. 75 #201 OVCKETE V.XION - A LEJANDRO G LVcrER0 $ 1083.17 dOL RECEIVED DEC 2 1 2015 MAR ICOPA COUNTY CLERK BOARD OF SUPERVISORS 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: PniTamant I hu5 h On or about t2—/OS/12-0 (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 warran( c t/ 14e.ck be issued to him/her in . the sum .. of $ 16/./.."-?5 .(3) Signe* (4) ( (5)-- bscribed o before me this il+ft day of 1- IS— . 'QOTARY PUBLIC OFFICIAL SEAL BARBARA M. SILL Ncorrimission expires: Notary Public - Arizona 3 / 1 ±/ 19 My MAR Commission ICOPA COUNTY Expires (seal) ,..k.UGUST 14,2019 Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issyed, \14ekr't-c-44 Warrant/Check Number / (if known) (6) I&OOLI3T7N LiC2iz2LN Original Date of Issue (if known) (7) 12-/o / 2o i APPROVED Reqson for original issue of Warrant/Check (8): X- Payroll (L61- ) DATE. DEN 1 201 El For Services or Goods furnished K. BOARD OF SUPERVISORS LI Other: A 7-RICOPA COUNTY S; \PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools \Schools-Warrants Checks notice of claimdoc Revised June 2015 A.R.S. 11-632 & 15-999 AFFIDAVIT APPROVED DATE., Da 21 2015 STATE OF ARIZONA AP' 1111=':KJA Os SUP.- F4°41214;i1 SORS COUNTY OF MARICOPA MARICOPA COUNTY ALEJAADRO G L.-LICER.0 , being first duly sworn, upon oath deposes and says: That on the - day of 20 , he presented to 1,2)idENIE (.1/\116/•1 District of Maricopa County, Arizona, for payment, a claim for services rendered or supplies furnished during the month of /\)64 EM I3E R_ 2015 , said claim being in the sum of ORE 114OL154AID EIGHT,/ THREE ergo Dollars, ($ 1083. 17 in payment of which the Superintendent of Schools caused his/her Warrant Number I OW b5g to be issued on NIOVeinbex- )Z , 20 , drawn on the Fund of 3LcKE/E c..141,1 1-k S District of Maricopa County, Arizona. Affiant further says that although he/she 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/her a duplicate of said Warrant Number 6)00 35(058 in the sum of $ 3, . _SubscrIbedaaridsw_orii ipeore me this tee day of ._ ,20 I C LESLIE DOUD Notary Public - Arizona Maricopa County 4r3 1A0 My Comm. Expires Nov 14, 2017 NOTARY PUBLIC Following approval please return this affidavit to the Maricopa County School Superintendents Office.