STAMPED AND REDACTED - 3700946719 - PYE BARKER FIRE AND SAFETY (002).PDF
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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. PYE BARKER FIRE AND SAFETY (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 0211912026 (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, Qt it was not presented for payment within one year alter 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 $,_7_2_9_-3_6 ________ .(3) Signed:ŕ (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 l ( #- day of CJl< N 20. e:uex /JpJVuCJ-- NOTARY My commission expires: e/df2!)w Warrant/Check Number if known 6 Original Date of Issue if known 7 3700946719 02/19/2026 Reason for original issue of Warrant/Check (8): □Payroll OFFICIAL SF.AL CRYSTAL L TORRES NOTARY PUB UC. ARIZONA MARICOPA COUNTY COMM #68839'1 y Comm. Exphes August 20, 2029 Iii for services or Goods furnished Pye Barker invoices 7823593 & 7828654 (seal) □Treasurer's refund/payment _______________ _ □Other: ______________________ _ S:\PROCESSES\Warrants - Oupllcate or Stale\02 Forms\Warrants Checks notice of claim - copy.doc Revised April 2015 A.R.S. 11-632 & 11-644