STAMPED BRIANNA FRANCIS ROUSSEL.PDF

INTEROFFICE MEMORANDUM

Maricopa County Schools Superintendent Office

TO: CLERK OF THE BOARD

FROM: Terri Ysaguirre

SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 12/17/2021

Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next
available Board agenda

Vv The attached item(s) have been researched to ensure that the warrant(s) in question have
not been cashed or previously re-issued.

v The original warrant(s) have had a stop payment done.

If you have any questions, please contact Terri Ysaguirre at 602-372-1245 or via e-mail at
terri. ysaguirre@maricopa.gov. Approved Affidavits may be routed back to the Superintendent
of School Finance Division at 4041 N. Central Avenue #1200, (12th Floor)

Thank you.

#17 Tolleson Elementary Brianna Frances Roussel $1,167.97

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.

BRIANNA FRANCES ROUSSEL (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 12/07/2021 (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 me in the sum of $ 1167.97 (3)

Signed: b wh, Outs (4)

1

(5) Subscribed and sworn to before me this [5th day of Decem ber 20 al :

Qvan
rari + . Notary Public - Arizona
My commission expires: Maricopa County
Commission # 581313 (seal)
Sait" My Comm, Expires May 5, 2024

NOTARY PUBLIC

ISABEL DEL TORO

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 3700491342

_(if known) (6)

Original Date of Issue 42/07/2021

_(if known) (7)

Reason for original issue of Warrant/Check (8):
Payroll
C1 For Services or Goods furnished 12/21/2021

OO Other:

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 ARS. 11-632 & 15-999