STAMPED & REDACTED JONATHAN FLORES.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.
+ X\ #1), being first sworn, upon oath deposes and says:
ame, Iman
On or about MLN W.2020 — (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/check be issyed to him/her in the sum of $_4500 (3)
(4)
rat SaSSSE: ae
scribed and sworn to before me this 23 day of _—~ Un@. 2022/.
LLL], Whe 4 alll
NOTARY PUBLIC
TAMMY NORRIS
My ion wy Cacunty
on Commission # 577175
Mefe mY wy Comm. Expires Jan. 5, 2024 (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 ?
4900335 Diy | Li} (24§ 3.3 ©
(if known) (6)
Original Date of Issue
(if known) (7) JULY \4 2620
Reason for original issue of Warrant/Check (8):
1 Payroll
O For Services or Goods furnished
OY Other: SCNDOL _ Sugh\ics 2 Books ( (wees Act )
07/14/2021
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrai /j
Revised June 2015 =