STAMPED AND REDACTED - 3700951870 - FRONTLINE PLACEMENT TECHNOLOGIES.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/ Claim Form 
This application is for: Iii Duplicate or D Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 
COUNTY OF MARICOPA
Note: Numbers on this form correspond to numbers on the 
Instruction sheet which Is page 2 of this form. 
FRONTLINE PLACEMENT TECHN'(l), being first sworn, upon oath deposes and says: 
Name/Claimant 
On or about 0311112026 
(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 $._8_32_._33 
________ .
(
3)
Signed: --Wt/1,-· ćĈ
-----,>1-ĉ
-,cJ
,,..,,1/'.-0_1.-_. _//Ċ;{!-ċ-fl-------( 
4) 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
(5) Subscribed and sworn to before me this 
9th 
day of 
June 
20--26.-,
r. -"') 
\ (_t:-,.,··v,r“c, \\,\/{Y'i,((,\;Jtl”ll.'! 
NOTARY PUBLIC 
My commission expires:
Sei::,tember 22, 2028 
Warrant/Check Number 
3700951870 
(if known) (6) 
Original Date of Issue 
0311112026 
(if known) (7) 
Reason for original issue of Warrant/Check (8): 
□ Payroll
Commonwealth of Pqnn1ylvanla • Notary Seal 
PAMHAA ROIMNOWSKl • Uotary Public 
Ch.ester Covnly 
My Comm!11lon l:xp!re\ September 12, 2028 
(seal) 
Comm!s1!onNumber 1272047 
■For Services or Goods furnished ________________
□Treasurer's refund/payment ________________ _
□Other: _______________________ _
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc 
Revised April 2015 
A.R.S. 11-632 & 11-644