STAMPED AND REDACTED - 3010246357 - MIRANDA PIETRO.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: liJ 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.
_M_i_ra_n_d_a_P_i_e_tr_o ______ (l), being first sworn, upon oath deposes and says:
On Name/Claimant or about 07/15/2026 (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
warrant/ im/her in the sum of $_1_3_0_.9_0 _______ . (3)
Signed: -JL--1'--4!:.../l-_!'1.c'.....1.--1--------------'( 4)
Print name: '----'--'-------'__::c:_:_ d{A Pudvu _______________ _
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued
11/
My c _ ommis_sir expires:
0 21 2,;1 :Jl)
Warrant/Check if known Number 6 3010246357
Original Date of Issue 07/15/2026
if known 7
Reason for original issue of Warrant/Check (8):
□ Payroll
□For Services or Goods furnished ___ řŚśŜŝ-Ş------
□Treasurer's refund/payment ___ _,_f_-u "'-.L._N._li.L)---"'l'"-'lLC:1!-: ____ _
ş Other: VC2170188-1-rqst3
Revised S:\PROCESSES\Warrants 100518 ` Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice A.R.S. of claim.doc 11 632 & 11-644