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INTEROFFICE MEMORANDUM Ilaricopa County Education Service Agency TO: Clerkof the Ooard FROM: Ersa Perez SUBJECT: Affidavits — Replacement of Lost /State Warrants DATE: 11/17/2015 Pase find attached Affidavit/Notice of Claim(s)for Cost warrants for inclusion on the next availaôfe Ooard agenda. -\1 The attached item(s) have 6een researched to ensure that the warrant(s) in question have not 6een cashed or previously re-issued The original-warrant(s) have had a stop payment done. If you have any questions, p&ise contact Ersa Perez at (602) 506-3533 or via e-mail at garnishments@mcesa.maricopa.gov. Approved Affidavits may 6e routed 6ack to the Maricopa County Education Service Agency at 4041 911: Central-Avenue #1200, (12th Eloor) Thankyou. 'Fund 781 .71-EIDI LA M $243.03 'E ED NOV 1 9 2015 \RICOPA COUNT'. CLERK BOARD OF SUPERVISORS cd_A_ jib netai Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: g 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. GUGLIELMO AND ASSOCIATES (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 9/3/2015 (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 belissed to him/her in the sum of $ 243.03 .(3) Signed: (4) Note‘fi‘ase attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn o before me this II-12 day of 00606C-- 20 1 0- . NOTARY PUBLIC KHYLEN WOOD Notary Public,State of Arizona Pima County My commission expires: My Commission Expires 11- August 06, 2017 (seal) - Warrant/Check Number 160015091 (if known) (6) Original Date of Issue 09/03/2015 (if known) (7) Reason for original issue of Warrant/Check (8): Payroll For Services or Goods furnished 111 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