STAMPED AND REDACTED - 3700989528 - GUITAR CENTER STORES INC.PDF

Schools Affidavit/Claim Form
Application for a Duplicate Warrant/Check
( 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.
C-1u.\!r;-o.._(" {:pA/\M,'< S\n<e'S (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about v..<:. I 1/f/,.q_date) (2) a warrant/check was Issued to the above-named
person/entity In the mount 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, Q[ 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
/ hr lnJ?e;;un o f $ '----'-----"L,..=. 4 VI 2· ____ 3\r • () 3
A
Signed: -----1==-='2..""-+-,L.---"u˒=----,1----(4)
.-··
Print name: (required) _ _____._{...,_jw' ,..,_$_.,,,0.-1.---'= (s=<.· ""C/"",!,"-', ('---'l--"˓----¥-- -----
(5) Subscribed and sworn to before me this ___ day of ____ 20_.
NOTARY PUBLIC
My commission expires:
(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
fif known) /6) 310Cffi?°l 5 2.f'
Original Date of Issue
(If known) (7) l.,LV\.'t.-vwu:>"'--
Reason for original issue of Warrant/Check (8):
□ Payroll
'.¢- For Services or Goods furnished ____________ _
□Other:
S:\FlnanceDesk\Schools-Warrants Checks notice of dalm.docx
Revised May 2025 A.R.5, 11·632 & 15-999