STAMPED & REDACTED LAKESHORE.PDF

INTEROFFICE MEMORANDUM

Maricopa County Schools Superintendent Office a ) ;
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RECEIVED ah
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TO: CLERK OF THE BOARD SEP 07 2021 «
sun en seas MARICOPA COUNTY
SUBJECT: Affidavits ~ Replacement of Lost Warrants CLERK BOARD OF SUPERVISORS

DATE: 9/3/2021

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.

#5 Isaac District Lakeshore $1,004.00

Schools Affidavit/Clain Forti

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.
Af ast e@ (1), being first sworn, upon oath deposes and says:

On or about Apr (3, XDI (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, ox 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

e/a to him/her in the sum of $ L, OOU . (0) (3)
Signed: Ae (4)

(5) Subscribed and sworn to before me this day of 20

See Abba AR

_NOTARY PUBLIC

My commission expires:
(seal)

Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

W. t/Check Numb:
aan | 3 - COLAS H4

Original Date of Issue
(if known) (7) 4- [3-2 [
Reason for original issue of Warrant/Check (8):
O Payroll .
(For Services or Goods furnished Seiices
O Other:

09/8/2021
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrant:
Revised June 2015

CALIFORNIA JURAT GOVERNMENT CODE § 8202

A notary public or other officer completing this certificate verifies only the identity of the individual who signed
the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California

County of tos Oona rte
fa)

Subscribed and sworn to (or affirmed) before me on

te
this_2 day of Se 202>\_, by
Date Month Year

(1) OS Vad Parcitheme Carer
(and (2) ail )

Name{s) of Signer{s)

MARY E. STEVENS
Notary Public - California
Los Angeies County
Commission # 2326422
My Comm. Expires May 8, 2024

3
5

proved to me on the basis of satisfactory evidence to
be the person{s) who appeared before me.

Signature aN Qe Ee Shera

Place Notary Seal and/or Stamp Above Signatued of Notary Public

OPTIONAL

Completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.

Description of Attached Document

Title or Type of Document:

Document Date: Number of Pages:

Signer(s) Other Than Named Above:

©2019 National Notary Association

Lakeshor

To whom it may concern:

Shannon Ceron is an official signer for Lakeshore Learning Materials.
If you have any questions, please feel free to reach out us.

Kind regards,
Pabner

ttle Palmer
Lakeshore Finance Department