STAMPED & REDACTED BROWN'S PARTSMASTER INC.PDF
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Office of the Maricopa County Finance Desk School Superintendent mm 20201016 Warrant Void/Stop Request District Name / Number: West-MEC #402 Attachments: Contact Name: Christina Pina [| Original Warrant Contact e-mail: christina.pina@west-mec.org Lost Warrant Affidavit (required for ALL reissues) Vendor Letter (if requesting Vendor reissue) Warrant Number Warrant Date | Amount Payee (starting with “37") (mm/dd/yyyy) (as it appears in Check Manager) Date Void Stop Re-issue << 3700467 173|9/14/2021|$ 167.82 Brown's Partsmaster Inc. O® ©ou OO OOo Amount Manes Check was lost in the mail District Approver: fie EY Date: \ | 2 baa For Internal Use Only Clerk of Board Date: Void Report Date: Reissue WT # BROWN’S PARTSMASTER, INC. Your Headquarters For Quality Plumbing Parts & Superior Service. RECEW ED pec Satisfaction Guaranteed! December 8, 2021 Western Maricopa Education Center Glendale, AZ 85305 This serves as notification that Angelica Cadena-Roman is authorized to sign the Affidavit/Claim Form and her signature must be notarized. Sincerely, ow Garrobo Controller CENTRAL DISTRIBUTION CENTER * Glendale, AZ 85397-1810 . « Fax Website: 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. Brown's Partmaster Inc. (1), being first sworn, upon oath deposes and says: Name/Claimant On or about September 14,2021 (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 $ $167.82 (3) Signed: — = =x - (4) (5) Subscribed and sworn to before me this eh day of Decomher_ 20 44. NO ae PUBLIC rf My commission expires: JANINE M. GARROBO Noisy Public - Arizona copa County September 14, 2021 ssion #564307 (seal) My Commission Expires June §, 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 | 3700467173/402546547 (if known) (6) Original Date of Issue e hiexear September 14, 2021 Reason for original issue of Warrant/Check (8): QO) Payroll For Services or Goods furnished Misc Parts __ C1 (ethers Mise Parts 01/03/2022 S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Revised June 2015