STAMPED AND REDACTED - 3700958749 - AGUA FRIA HIGH SCHOOL.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: IiJ Duplicate or D Stale-Dated (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.
_A_Gr.cU""A""F˼R=lccA"'H'I_G_H_s_c_H_O_O_L ___ (1), being first sworn, upon oath deposes and says:
Name/C!a\mant
On or about 0410812026 (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 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
$_1,_3_53_._69 ________ .(3)
warrant/check be issued to him/her in the sum of
Signed: ˽ )Ad;. (4)
Note: Please attach a copy of the warrant/check if ava!'lab/e and/or any other
evidence that a warrant/check was oligina//y issued.
.,,_ Wit-
(5) Subscribed and sworn to before me this ::l.-0 dayof 20:i.f,,
'
˾
NO
Cecily Lewis
·.;:; Notary Public
My commission,:_2x i ;;._r˿ åri æ ,; Maricopa County, Arizcn•
"'I. -"\ - •• ... • ' My Comm. Expires 09-09-28 (seal)
Commission No. 674775
Warrant/Check Number 3700958749
(if known) (6)
Original Date of Issue 04/08/2026
!If known) /7\
Reason for original issue of Warrant/Check (8):
D Payroll
1111 For services or Goods furnished Migrant Ed Program Grant Reimbursement
D Treasurer's refund/payment _______________ _
□Other: _______________________ _
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644