STAMPED KARRINGTON DENIS MARTIN.PDF

INTEROFFICE MEMORANDUM

Maricopa County Schools Superintendent Office

TO: CLERK OF THE BOARD

FROM: Terri Ysaguirre

SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 10/28/2021

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.

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.

#79 Litchfield Elementary Karrington Denise Martin $1,210.33

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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.
Karrington Martin (1), being first sworn, upon oath deposes and says:
~~ Name/Claimant
On or about wei ae | 2or| (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

Sol al ail r ro the sum of $ 1210.33 (3)
Signed —= (4)

(5) Subscribed Aan sworn to before me this 22 A _ day of Qctob er 20AL.

Bilbo ; Brittany Carter

Notary Public
Maricopa County, Arizona
My Commission Expires
April 30, 2023
Commission No. 562528 (seal)

My commission expires:

30, Qoas

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 | 3799469824

(if known) (6)

Original Date of Issue 09/28/2021

(if. known) (7)

Reason for original issue of Warrant/Check (8):

Payroll 10/29/21

C1 For Services or Goods furnished
O Other:

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