STAMPED & REDACTED - FOR AGENDA ATTACHMENT - SAMANTHA JONES.PDF

INTEROFFICE MEMORANDUM 
TO: 
MARICOPA COUNTY CLERK OF THE BOARD 
FROM: 
MCSS FINANCE DESK (ANDIE DE LA ROSA) 
SUBJECT: 
AFFIDAVITS – REPLACEMENT OF LOST WARRANTS 
DATE: 
10/30/2023 
Please find attached 1 Affidavit/Notice of Claim(s) for lost warrants for inclusion on the next 
available Board agenda. 
The attached item(s) have been researched to ensure that the warrant(s) in question have not been 
cashed or previously re-issued. 
The original warrant(s) have had a stop payment done. 
If you have any questions, please contact the MCSS Finance Desk at 602-372-4833 (Option 1) or 
via e-mail at FinanceDesk@maricopa.gov. Approved Affidavits may be routed back to the 
Superintendent of Schools - Finance Desk at 4041 N. Central Ave #1100. 
Thank you 
District 
Payee 
Warrant # 
Amount 
Queen Creek Dist #95 
Jones, Samantha 
3700697989 
$914.20

Office of the Maricopa County
School Superintendent
District Nqme / Number: QCUSD/9S
Contoct Nome: Vicki Harberts-Gurule
contact e-moil:
Notes: Lost check.
District Approver:
'W arcant Void/Stop Request
ft Dor",
Atlochments:
Originol Worront
Losl Worront Affidovit (required for ALL reissues)
Vendor Letier (if requesting Vendor reissue)
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Finance Desk
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3700697989
Worront Number
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101312023
Worront Dote
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$ gt 4.20
Amount
Jones, Samantha
Poyee
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For Intemal Use On/1
Clerk of Boord Dote:
Void Report Dote:

Schools Affidavit/Claim Form
Application for a Duplicate Warrant/Check loetinitions are on page 2)
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STATE OF ARIZONA
COUNTY OF MARICOPA
Jones, Samantha
Note: Numbers on this form correspond to numbers on the
lnstruction sheet which is page 2 of this form.
.(3)
4)
1), being first sworn, upon oath deposes and says:
on or about i b
t_023
(oate)(2) a warrant/check was issued to the
above named person/
in the amount as stated below. Such warrant/check was
e
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 ctaim 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 g 914.20
Signed:
and sworn to before me this 2U 
day of .ylfj\oef 20pf
(5) Subscri
NOTARY PUBLIC
My com
(seal)
res:
Note.' Please attach a copy of the warant/check if avaitable and/or any other
evidence that a warant/check was originally issued.
Reason for original issue of Warrant/Check (B):
E Payroll
n For Services or Goods furnished
tr Other:
S:\PROCESSES\Warrants - Duplicate or Stale\O2 Forms\Schools\Schools-Warrants Checks notice of claim,doc
Revised June 2015 
A,R.S. 11-632 & t5-999
Warrant/Check Number
(if known) (6)
3700697989
Original Date of Issue
(if known) (7)
f0 3 2023

10/30/23, 10:33 AM
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