STAMPED AND REDACTED - 3010240747 - AGUA FRIA FOOD AND CLOTHING BANK.PDF

Application for a Duplicate or Stale Dated 
Warrant/Check Affidavit/Claim Form 
___!!11s application Is for 
9 Duplicate or D Stale-Dated (definitions are on page 2)
ST ATE OF ARIZONA 
COUNTY OF MARICOPA 
Note: Numbers on this form correspond to the numbers 
on the Instruction sheet which is page 2 of this form 
_A__,g.._u_a_F_rl_,a,....F_o_o...,d....,A_nd_C_l_ot_h_in
_,g..__B_a_n_k __ (1 ), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about 
05/07/2026 (date) (2) a warrant/check was issued to the above named
person/entity In the amount 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 Issues to him/her in the sum of $255.00 
. (3)
Signed: ȍ1'!1toȎ,0 '. Z¥Mc- -
(4)
Print Name: (required) Kaȏ 
cl.aughlm 
ii 
Note: Please attach a copy of the warrant/check if available and/or any other evidence that a
warrant/check was originally issued.
My commission expires:
II-do- lo21p
Warrant/Check Number
{if known) {6) 
Original Date of Issue
{if known) (7) 
(i LEONA.RD RAY LEDBm£tt 
NotMy Public -Arizona 
Mark.opa County 
CommlsMOn I 6409]1 
My Comm, ExplrH Nov ,, 2026 
3010240747
05/07
Reason for original issue of Warrant/Check (8):
(seal)
0 Payroll __________________________ 
D For Services or Go.eds furnished __________________ 
D Treasurer's refund/payment __________________ _
0 other: Refund of jobber's permit-Ȑ 1)%0 -BN\I dlcnrocf\f-A'L Se,a.vic.e..s·
f\)AO 5t>'o , '2,A)C-i-1) Jlo 1--1tc9J.I ,eio\-\ i::e.e.- \i-JA-\\/e.r rol)sso3
S;\PROCESSES\Warrants- Duplicate or Stale\02 Forms\Current Claim Form\ 100518 Warrants Checks notice of claim.doc Revised 
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100518 
7..<JO 
A.R.S.11-632&11-644