STAMPED AND REDACTED - 3010244037 - EPCOR USA INC..PDF

MAR COPA Application for a Duplicate or Stale Dated
COUNTY Warrant/Check Affidavit/Claim Form
This application is for I✓ I Duplicate or D Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form
_E_P_C_O_R_U_S,..,.A_.,.,.,..-,--_________ (1), being first sworn, upon oath deposes and says:
Name/Claimant
on or about June 17, 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 issued to im/her in the s f $139.32 . (3)
(4)
Print Name: ( quired) _K_e_ls_ey ,__B_ar_n_ha_rt ____________ _
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 swɰ..:!/:lme this 24th day of August 203§__.
----:-&✓✓
NOTARY PUBLIC '
TODD M. VESLEDAHL
Nola,yPuÈio
C-Ommlsslon Number 654200
My commission expires: Expires: June 22; 2027
Maricopa Coun (seal)
(..,/p,2/20:;;..7-=
/ '
Warrant/Check Number
(if known) (6)
Original Date of Issue
06/17/2026
(If known) (7)
Reason for original issue of Warrant/Check (8):
□ Payroll ____________________ ----,--------,,--
Services or Goods furnished EPCOR water Account# 660912 / F' ()J\1 D : ) QQ
[Z] For
□Treasurer's refund/payment ___________________ _
□Other: __________________________
S:\PROCESSES\Warrants- Duplicate or Stale\02 Fonns\Current Claim Form\ 100518 Warrants Checks notice of claim.doc Revised
100518
A.RS. 11-632 & 11-644