STAMPED AND REDACTED - DAVID LAROSE.PDF
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v MAR)COPA COUNTY INTEROFFICE MEMORANDUM TO: MARICOPA COUNTY CLERK OF THE BOARD FROM: MCSS FINANCE DESK (MIKE MARTINEZ) SUBJECT: AFFIDAVITS — REPLACEMENT OF LOST WARRANTS DATE: 11/13/2025 Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next available Board agenda. The attached item(s) have been 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 the MCSS Finance Desk at 602-372-4833 (Option 1) or via e-mail at FinanceDesk@maricopa.gov. Approved Affidavits may be routed back to the Superintendent of Schools - Finance Desk at 4041 N. Central Ave #1100. Thank you District Payee Warrant # Amount Litchfield Elementary #79 _| DAVID LAROSE 3700907975 $10,500.00 Date: Amount: Reissue WT # \ : : . MA a) ¢ @) PA District #: COUNTY District Name: Litchfield Elementary School District #79 Contact Name: Brittany Carter Contact Email: WARRANT VOID/STOP REQUEST Warrant # 3700907975 Warrant Date 99/23/2025 Warrant Amount $ 10,500.00 Payee David LaRose Choose one option: O Void Warrant Warrant is in possession of the district and will be sent back to MCSS Finance Desk with the next available courier run. © Stop Warrant Warrant has been lost or destroyed and is not in possession of the district. If requesting MCSS to reissue this warrant select the Reissue Warrant box below and submit a notarized affidavit along with a vendor letter (if payee is not an individual). Reissue Warrant: Notes: Lost in Mail District Approver: Brittany Carter Date: 44/06/2025 Revised 10/8/2025 Schools Affidavit/Claim Form M AICOPA Application for a Duplicate Warrant/Check COUNTY (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF OPA Instruction sheet which is page 2 of this form. Des vi d l« ote (1), being first sworn, upon oath deposes and says: Name/Claimant On or about o/h Zr [- WLS (a (date) (2) a warrant/check was issued to the above-named person/entity in Zhe améunt 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 ev warrant/check be issued to him/her in the sum of $ [ d, 6B. (3) al Signed: Z _(4) 7 Print name: (required) [Z ud Ls Kase (5) Subscribed and swom to before methis_20 _day of Ovlxr 20Z5_. rf » NOTARY PUBLIC PAULA MELENDEZ Notary ID #128752189 My commission expires: ’ My Commission Expires 5 2uj2ozg May 24, 2028 (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 (if known) (6) 330090942¢ | LaF(,0013 ) / Ages Original Date of Issue cz (if known) (7) O23 1202S Reason for original issue of Warrant/Check (8): O Payroll. © For Services or Goods fumished Ya Gn WS, O Other: S:\FinanceDesk\Schools-Warrants Checks notice of caim.docx Revised May 2025 ARS, 11-632 & 15-999 David LaRose Educational Coach/Consuitant Date: October 29, 2025 To: Litchfield Elementary School District Attn: Accounts Payable From: David LaRose Re: — Authorized to Sign t operate my business as an independent/sole proprietor; therefore, | am the authorized signer for all matters related to contracting, invoicing and payment. 11/13/25, 10:54 AM Maricopa County - Treasurer's Office - Agency Web Warrant Maintenance New Warrant Upload Warrants WARRANT DETAILS FOR LITCHFIELD ESD 7 Warrant Number - Amount 3700907975 $10,500.00 Po = 25 r Status r Payee Name Void DAVID LAROSE AGENCY INFORMATION (OPTIONAL) < Back To Warrant Search https://treasurer.maricopa.gov/agencyweb/WarrantMaintenance/Warrants/1117162 11