STAMPED AND REDACTED - 3700971483 - ROSA RODRIGUEZ.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (definitions are on page 2)
STA TE OF ARIZONA 
Note: Numbers on this form correspond to numbers on the 
COUNTY OF MARICOPA 
Instruction sheet which is page 2 of this form. 
_RȓO=D=R=IG=UȔE_Z.:..., _R_O_S_A_A ___ (l), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about O 5-;J 6 
(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, m: 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 $,_1_0_3_3_.5_1 _______ ,(3)
Signed: <J(  A 12,4:-,-
(4) 
(5) Subscrlb
f 
and sworn to before me this -ȕ-day of '.J \)'{\).___, 20..d.le
---· 
My comllJl¢l9]) <1>.Wires; ()
DSU,4_(LO y 
CASS 
D 
Nola,y Public. State of Arizona 
PINAL COUNTY 
Commission # 692627 
Expires May 8, 2030 
(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 
3700971483 
(If known) (6) 
Original Date of Issue 
05/26/2026 
Of known l (7) 
Reason for original issue of Warrant/Check (8):
ii Payroll 
□For Services or Goods furnished. _______________ _
□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