STAMPED & REDACTED DANIEL LIGUORI.PDF
Extracted text (via tesseract_tsv)
18992 characters
Maricopa County
. aw nl
RECEIVED yar!
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5 1 6 1 2 1 271 1213 175 49 94.536453 Date:
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5 1 15 1 1 2 461 2600 116 48 96.286713 you.
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/ Claim Form
This application is for: CJ Duplicate or L] 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.
“ ¢| “
AN \ GJol\ (1), being first sworn, upon oath deposes and says:
Name/Claimant °
4 [ Y/ Va |
On or about (date)(2) a warrant/check was issued to the
above named person/eéntity 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
7 6&: 3 q
warrant/check be issued to him/her in the sum of $ (3)
Baw
NAVEL,
Signed: (4)
~ GY
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this \9 day of ror) 202
Qu LIMO) reas
NOTARY PUBLIC
EILEEN ie JAMS-PREAS
- y commission i expires: MARICOPA if s
COUNTY
UA» d0a.2- ar rember 8, 2022 (seal)
—
Warrant/Check Number 2.20 S Be “1)
(if known) (6)
Original Date of Issue Lhliy
\2]
(if known) (7)
Reason for original issue of Warrant/Check (8):
&D Payroll
O For Services or Goods furnished
04/20/2021
O Treasurer’s refund/payment
1) Other:
Revised April 2015
-Liguori, DanielE ; Company: MC1_ Off Cycle: N
_ MC1-MaricopaCounty Pay Group: NEX Separate Check # 0
_
F=— 5143 - Sheriff Information Mamt syst Period End 04/04/2021 Reprint: N
a
M)) NEX-NonExempt — Page. 1001 Adjustment: N
Active - 09/08/2021 ReglFT
:
Liguori,
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