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INTEROFFICE MEMORANDUM
Maricopa County Schools Superintendent Office
TO: CLERK OF THE BOARD
FROM: Terri Ysaguirre
SUBJECT: Affidavits - Replacement of Lost Warrants
DATE: 12/13/2021
Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next
available Board agenda
v The attached item(s) have been researched to ensure that the warrant(s) in question have
not been cashed or previously re-issued.
Vv 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.
#216 Agua Fria Union Steven Taylor $481.14
MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
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.
SheVeEN Tau lote. (1), being first sworn, upon oath deposes and says:
Name/Claimant fa)
On or about _(\- 23-2 (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
a dy. to him/her in the sum of $. L{sl ‘ iY (3)
} =
Signed: L jayl 4
g i (4)
(5) Subscribed and sworn to before me this ye day of (deeem\oer 202.
ee)
NOTARY PUBLIC (
ELSA M. CHAPA
Notary Public - Anzona
| See MARICOPA COUNTY
\ ES Commission # 593835
Te” Expires September 30, 2024 (seal)
My commission expires:
il [As | wy,
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) Ar 0c BZOUT | WoW 3659
Original Date of Issue "
(if known) (7) (— 93-1
Reason for original issue of Warrant/Check (8):
x Payroll
1 For Services or Goods furnished
12/21/2021
QO Other: / .
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-\
Revised June 2015 ARS, 11-632 & 15-999