STAMPED & REDACTED BROWN'S PARTSMASTER INC..PDF

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.

#79 Litchfield Elementary Brown’s Partsmaster, Inc $494.78

RECEIVED tere

AUG 1 0 2021

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.

BROWN'S PARTSMASTER, INC (1), being first sworn, upon oath deposes and says:

Name/Claimant

On or about 06/03/2021 (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 $494.78 . (3)

Signed: <— wee 2 En La : (4)

(5) Subscribed and sworn to before me this >oih day of —J ase 20>.

TARY PUBLIC

e

JANINE M. GARROBO
Notary Public - Arizona
Maricopa County
Commission #564307 (seal)
Commission Expires June 5, 2023

Mv commission expires:

Tune 3, 20a,%

SS

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 | 3790431438/79740904

(if known) (6)

Original Date of Issue 06/03/2021

(if known) (7)

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

f@ For Services or Goods furnished___— 08/10/2021
O Other:

$:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Wart
Revised June 2015

A.R.S. 11-632 & 15-999

MARICOPA COUNTY SCHOOL SUPERINTENDENT
4041 N Central, Suite 1100
PHOENIX, AZ 85012 ;

TO: PAYROLL - ACCOUNTS PAYABLE
PLEASE STOP PAYMENT AND REISSUE THE FOLLOWING WARRANT:

DISTRICT NUMBER: OL

PERSON REQUESTING

STOP PAYMENT: Beverly Marstal{ PHONE #: EXT:

WARRANT NUMBER: 377? -_00 43/438 WARRANT DATE: _OG / 05 / ae
(prefix) (number) (mm) (dd) (yy)

PAYABLE TO: GB Rows PARTSMASTER ENC

AMOUNT: Hay4.75

FUND NO: oYe VOUCHER NO: 9532.

CHECK ONE: EXPENSE PAYROLL

REASON FOR STOP:
Check was leS+ ia Mail= please reissue

(LOST, DESTROYED, ETC.)

ONE ORIGINAL AFFIDAVIT AND ONE COPY OF THE AFFIDAVIT ARE ATTACHED. PLEASE
ISSUE A REPLACEMENT WARRANT. :

(FOR COUNTY USE ONLY)
STATUS VERIFIED:
STOP DATE: REPLACED:
STOP VERIFIED: WARRANT #:
AFFIDAVIT SENT:
AFFIDAVIT APPROVED:

RECONS RETURNED: STOP PREPAID

Revised 4/5/07
\\Moss_411\data\Repository\Share\PayRoll\Front Desk (finance) sample memos, etc\LOST WARRANT STOP-REISSUE COVER SHEET.doc

> ie -
BROWN’S PARTSMASTER, INC.

Your Headquarters For
Quality Plumbing Parts
& Superior Service.
Satisfaction Guaranteed!

July 30, 2021

Litchfield Elementary School District #79
Attn: Accounts Payable / Beverly

Beverly,

This serves as notification that Angelica Cadena-Roman is authorized to sign the Schools Affidavit/Claim
Form and her signature must be notarized.

Sincerely,

Janine Garrobo
Controller

CENTRAL DISTRIBUTION CENTER

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