STAMPED JUDITH HERNANDEZ ROSALES.PDF

INTEROFFICE MEMORANDUM

“Maricopa County Schools Superintendent Office

TO: CLERK OF THE BOARD

FROM: Terri Ysaguirre

SUBJECT: Affidavits —- Replacement of Lost Warrants
DATE: 8/9/2021

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.

#95 Queen Creek Unified Judith Hernandez Rosales $611.47

RECEIVED tat

AUG 10 202i

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.

HERNANDEZ ROSALES, JUDITH (1), being first sworn, upon oath deposes and says:
Name/Claimant

On or about 97/27/21 (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/checkjbe issued to him/her in the sum of $61 1.47 (3)

Signed: @ br Lu Ly (4)

(5) Subscribed and sworn to before me this Ss day of Ah ag st 2a.

NOTARY PUBLIC

CYNTHIA SKORO
. . . lic« Anzona
My commission expires: hacer A COUNTY
AL COL
A) 0/2 cas Beccary (seal)

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

WarrantCheck Number " 13700448870

(if. known) (6)

Original Date of Issue
9 (if known) (7) 07/2 7/2 1

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

08/10/2021

O For Services or Goods furnished
CO) 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