STAMPED AND REDACTED - 3010241317 - VIQ SOLUTIONS, INC - $1712.80.PDF

Application for a Duplicate or Stale Dated
Warrant/Check Affidavit/Claim Form
This application 11:1 for liJ Dupllc11te or lJ st11le-D11ted (deflnhlon1 .,. on page 2)
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STATE OF ARIZONA N;;I;;:· N11111h;;Y;;;n 1i11.· ,;;;,.;, Z;;,r;;;j,on.i·,;; iite m1mbero
COUNTY OF MARICOPA 011 the lhaltuctlotl sheet which I[ page 2 of this form
VIQ SOLUTIONS, INC. (1 ), lmh11J first nworn, upon oath deposes and says:
Nsmr/CIAhmmt
On or nbout 15-M/\ Y-2026 (cintn) (?) 11 wnrrnnl/dmck w1w lr.mJ!id to the 1-bove named
person/entity In the n11101111t Rlnlnd h,ilow. 1·111ch w11rrn111/d1nck wnn el1her never received or
was subsequently lnadve1t1mtly hml 01 dnit11oy(!cl und lhmo Is no roanonable probability of its
being found 01 prnsented for pnymcnt, <1r It wnn not prnoN1lnd for payment within one year
after the dale of ISSllA11G<'.
Therefore, undei penalty of p1Ϛ1j111y, claimant hereby affirms that this claim Is correct and the
amount shown Is <lun R11<l owlnti, an<l the applicant requests that a replacement warrant/check
be Issues to him/her In the sum of $1, 712.80 (3)
Signed· ztj (4)
Print Name: (required) -ϛL=a=rϜry_Tϝa=y'-'-lo=r ___________ _
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 M!:!lday of Au8u -\- 20Ϟ
c,,:lf-f2<ϟ -;::.
NOT ARY PUBLIC
---
A. Nttaiy Public State of ftorlda
O,Ytlal Oliphant •
My commission expires: My CommlHlon HH OOSIQ •
Explm 4/201202t , (seal)
OfJ.,;J,,'r/-\0'.)_Qi
Warrant/Check Number
(If known)(6) 3010241317
Original Date of Issue
15-MAY-2026
(If known) (7)
Reason for original issue of WarranVCheck (8):
□Payroll ______________________ _
□ForSelVlcesorGoodsfurnlshed _______________ _
□Treasurer's refund/payment _________________ _
1ZJ Other. AJNO 100 -1.N. Z6'fi7408 & 26'682.fi3 • INV# VIQU100114 & Vtt1u10120 - TRANSCRIPTION SERVICES
S!\PRoceJSES\waminta-l)IJpllcaleorstale\02Fums\CumwEclal01 Fom,\100518Wu,mnlsChooksnoUoeofclalmdooR<wled
100518
A.R.8.11-632&11-644