STAMPED AND REDACTED - 3700964242 - GATEWAY COMMUNITY COLLEGE.PDF
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r) lE ® lE o w [E -1 ill) JUN J l 202G ILJ SchoolsAffidavit/claimForm By_ . MAR@COPA Application for a Duplicate Warrant/Check COUNTY (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. Gateway Community College (1 ), being first sworn, upon oath deposes and says: Name/Claimant On or about 04/29/2026 (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, Qr 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$ 86,682.00 ,) ,. - Signed: ( / (;"-.. (4) Print name: (required), _ _,(_' <l\ci -·/:___·-Lr"-· ------- . (3) (5) Subscribed and sworn to before me this C\ t\l\ day of dJ;\ Qe,, 20 ·7-Jo. lY(v\ f::bnvie \l,4 t.Jvv NOTARY PUBLIC My U01nmisslon expires: \0 (9 ( :Z,0111 - .. (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 3700964242 /If known\ /6) Original Date of Issue 04/29/2026 /If known) /7) Reason for original Issue of Warrant/Check (8): D Payroll lil For Services or Goods furnished ____________ _ D other: S:\FlnanceDesk\Schools-Warrants Checks notice or clalm,docx Revised May 2025 A,R.S. 11-632 & 15-999