STAMPED & REDACTED KIM, SUJIN.PDF

INTEROFFICE MEMORANDUM 
TO: 
MARICOPA COUNTY CLERK OF THE BOARD 
FROM: 
MCSS FINANCE DESK (ANDIE DE LA ROSA) 
SUBJECT: 
AFFIDAVITS – REPLACEMENT OF LOST WARRANTS 
DATE: 
08/05/2022 
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 (Option 1) or via e-mail at. 
Approved Affidavits may be routed back to the Superintendent of Schools - Finance Desk at . 
Thank you 
District 
Payee 
Warrant # 
Amount 
Queen Creek Dist #95 
Sujin Kim 
3700545825 
$300.00

Reissue WT # 
Amount 
Date 
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Notes: CHECK NEVER ARRIVED TO PARENT. PARENT REFUND. 
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Warrant Number 
(starting with "37") 
6/7/2022 
Warrant Date 
(mm/dd/yyyy) 
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Amount 
SUJIN KIM 
Payee 
(as it appears in Check Manager) 
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Contact e-mail: AJOHNSON2@QCUSD.ORG 
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District Name / Number: QCUSD 95 
Vendor Letter (if requesting Vendor reissue) 
Lost Warrant Affidavit (required for ALL reissues) 
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Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (definitions are on page 2) 
STATE OF ARIZONA 
COUNTY OF MARICOPA 
SUJIN KIM 
Note: Numbers on this form correspond to numbers on the 
Instruction sheet which is page 2 of this form. 
Name/Claimant 
On or about 06/07/2022 
(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. 
(1), being first sworn, upon oath deposes and says: 
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 $300.00
Signed: 
.(3) 
Note: P/ease 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) 
3700545825 
Original Date of Issue 
(if known) (7) 
06/07/2022 
Reason for original issue of Warrant/Check (8): 
K Payroll 
K For Services or Goods furnished SUMMER SCHOOL REFUND 
Other: SUMMER SCHOOL REFUND 
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

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