STAMPED AND REDACTED - 3010244471 - DEDICATED DRAGONFLY THERAPY LLC.PDF

MA COPA Application for a Duplicate or Stale Dated
COUNTY Warrant/Check Affidavit/Claim Form
This apPlication is for I e,/ I Duplicate or D Stale-Dated (definitions are on page 2)
ST ATE OF ARIZONA lllote: !\lumbers on this form correspond to the numbers
COUNTY OF MARICOPA on the Instruction sheet which is page 2 of this form
DEDICATED Name/Claimant DRAGONFLY THERAPY LLC(1), being first sworn, upon oath deposes and says:
On or about 6/22/2026 (date) (2) a warrant/check was issued to the above named
person/entity in the amount 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/check
be issues tǻher in the sum of $475.00 . (3)
Signed: Ǽ QJJ,1J , (4)
Print Name: (required) --'",11-\-ǽ"'-"--'-''--'---":L...:..n..,__ _________ _
Note: Please attach a cop of the warrant/check if available and/or any other evidence that a
warrant/check was originally issued.
(5) Subscrib>Ǿ, aǿ.- swprn .i-e, to befor (e ) me this i I b , " day of .){· .- r \1 _1 if ,, ,,:0:1,, 2 0 _;;:i__r;,_.
NOTARY PUBLIC - \J, >\ ·, , M r, ""T""- ' - -
I ta ,., _ 1<Esr iJ ,., Notar; SUCHITHRAKUMAR Markopa Public· County Adrnca
My commission expires: I 1 ,.3 • 1;11 - A 1f: My Comm, Commission# Expires Jul 695316 27, 2030
-::f ,Q 7 ::2J i, 'l o: ., ... 0 \'---'/
Warrant/Check (if known) Number (6) 3010244471
Original Date (if known) of Issue (7) 6/22/2026
Reason for original issue of Warrant/Check (8):
□ □ For Payroll Services __________________________ or Goods furnished _ r- (J t r/J_i' =aȀ I .... ȁ---------- _
□Treasurer's refund/payment ____________________ _
□Other: __________________________ _
S:\PROCESSES\Warrants 100518 - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised
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