STAMPED & REDACTED ADOLFSON & PETERSON CONTRUCTION.PDF

INTEROFFICE MEMORANDUM

Maricopa County Schools Superintendent Office

TO: CLERK OF THE BOARD

FROM: Terri Ysaguirre

SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 9/27/2021

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.

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.

#02 Riverside Elementary Adolfson & Peterson Construction $16,978.61

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.

ADOLFSON & PETERSON CONSTRUCTION (1)
Name/Claimant "

being first sworn, upon oath deposes and says:

On or about August 17, 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 pene e sum of $16,978.61 3)
Zoe Set

Signed: (4)

(5) Subscribed and sworn to before me this_\1"2 day of Sop son beA0 AL,

NOTARY PUBLIC

TRACIE BLACKWELL
Notary Public, State of Arizona
Maricopa County
Commission # 654363

My Commission Expires (seal)

Sessile BS

My commission expir
Ofifagaa

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 Numbe
Teton 6). (e/00457804

iginal Date of I
nl an August 17, 2021

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

@ For Services or Goods furnished MIT CONSTRUCTION
O Other: MIT CONSTRUCTION

09/29/2021

S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrant
Revised June 2015

Adolfson
& Peterson
Construction

September 22, 2021

Ms. Teresa Solares

Finance Specialist

RIVERSIDE SCHOOL DISTRICT #2
Phoenix, AZ 85043

RE: RIVERSIDE MIT — JULY PAYMENT

Dear Ms. Solares:

By way of this letter, please be advised the Mr. Vincent Castillo is authorized to sign the attached Affidavit /
Claim Form on behalf of AP Southwest dba Adolfson and Peterson Construction.

If you have any questions or desire additional information, please feel free to contract me at 480-7561871.

Sincerely,

fotif—

Scott Salyer

Regional Vice President

AP Southwest LLC

dba Adolfson and Peterson Construction

SS/tlb

Adolfson & Peterson Construction
| Tempe, AZ 85282
p lf |
we exist to build a better tomorrow

THIS WARRANT DRAWS INTEREST FROM DATE MARKED "INSUFFICIENT FUNDS* DATE a : CONTROL NO.
INTEREST STOPS ON DATE FUNDS AVAILABLE. (SEC 11-636, ARS1956)
08/17/2021 2054880
Riverside Elementary District #2 — . —
_ ++. ,WARRANT AMOUNT .._= | f
PAY
"Sixteen Thousand Nine Hundred Seventy Eight and 61/100*** Dollars $16,978.61

VOID AFTER 365 DAYS

TO ADOLFSON & PETERSON CONSTRUCTION
THE 5002 S ASH AVE

ORDER
TEMPE, AZ 85282-6843 ;
OF yA st
superintendent AGEhRARAZED SIGNATURES
"370057804" Wbe2bO00 ahi F?POLAGL dae
MARICOPA COUNTY SCHOOLS + PHOENIX, ARIZONA 08/17/2021 Check: 2054880 EXPENSE
AP 20210848 3700457804
ADOLFSON & PETERSON CONSTRUCTION | 08/17/2021
Payee l Check Date
Account Number PO Number Invoice Amount
63210047006450103 22127 APPNO: 12 16,978.61
PAID
AUG 18 2021

BUSINESS SERVICES

VOUCHER: 1014 TOTAL: $16,978.61

HARLAND CLARKE M22692 00229286