STAMPED AND REDACTED - 3701001888 - ROSHANDA RICHARDS.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
Instruction sheet which is page 2 of this form.
COUNTY OF MARICOPA
_Rǀoǁs_h_anǂdǃaDŽR_lc_h_a_rd_s ____ (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 09/0l/2□26 (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
/I
s_;
warrant/Dždžet}e IJ'ued tLJ hl111/hLjlj thNJ of Nj·-1nj,8 _5 _4._.Ǎ_7 _____ . (3)
1 f . i 1
Signed: L&dU1;.,1(t)lf! ( \,t'(ǎ.f:u;_,., ?J (4)
, ) .
j\:1x JǏc:q, 1c;G.1. /iv\ ' ((.( (I VtǐLl Pcf \
Print name: (required)
(5) Subscribed and sworn to before me this day ofSrp'lt 'YI l•.1l1 20 H,,
' ./ - )2 · ,·· )
j
NOT ARY PUBLIC ANGELA JONES
NOTARY PUBLIC •ARIZONA
MARICOPA COUNTY
COMMISSION #864904
MyCommlllllon El<plretAprll. 20. 2021
(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 3701001888
(if known) (6)
Original Date of Issue 09/01/2026
(if known) (7)
Reason for original issue of Warrant/Check (B):
Iii Payroll
□For Services or Goods furnished ____________ _
□Other:
S:\FinanceDesk\Schools·Warrants Checks notice of dalm.docx
Revised May 2025 A,R.5, I 1-632 & 15·999