STAMPED AND REDACTED - 3700984275 - DOLORES FLORES-TAPIA.PDF

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Schools Affidavit/Claim Form MARlCOPA
Application for a Duplicate Warrant/Check COUNTY
(definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
FLORES-TAPIA, DOLORES H (1 ), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 07121l20Z6 (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
be issued to him/her in the sum of $,_6_5_.3_6 ______ . (3)
-.
- I IA..
Signed: (4)
Print name:(required) Do/ore5 If. F(!Jre5 (qfl0...
1'
(seal)
Note: Please attach a copy of the warrant/check if available and/or any other evidence
that a warrant/check was originally issu?d.
Warrant/Check Number
(if known) (6) 3700984275
Original Date of Issue
(If known) (7\ 07/21/2026
Reason for original, issue of Warrant/Check (8):
Ļ Payroll ' •
□For Services or Goods furnished,ļ------------
□Other:
S:\FinanceDesk\Schools-Warrants Checks notice of cla!m.docx
Revised May 2025 A.R.S. 11-632 & 15-999