STAMPED NITA A. GOMEZ.PDF

INTEROFFICE MEMORANDUM

Maricopa Cou nty Schools Superintendent Office

TO: CLERK OF THE BOARD

FROM: Terri Ysaguirre

SUBJECT: Affidavits — Replacement of Lost Warrants
DATE: 9/1/2021

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.

#2 Riverside Elementary Nita A Gomez $2,032.71

RECEIVED

SEP 17 202}

MARICHA, ey,
CLERK BOARD Ofc (UNTY

a SUPERVISORS
ther otiee ya. AE

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.
Nita A. Gomez (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about July 22, 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 him/her in the sum of $ 2,032.71 .(3)

Signed: {\ dd b—% (4)

(5) VI ribed and swowy to before me this Zot day of Cucust 202/.
A oe hm —

NOTARY PUBLIC

commission expires:
202v2—

MARIA TERESA SOLARE >

Notary Public - Arizona
Maricopa County

Commission # 551060

My Comm, Expires Aug 2, 2022

(seal)

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) 3700446281

Original Date of Issue
9 (if. known) (7) July 22, 2021

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

C For Services or Goods furnished ’ 09/17/2021
O Other: 7

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