VICTIM COMP REPLACEMENT WARRANT 02.27.19.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Fi Duplicate or EZI Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
page 2 of this form.
Robin Sue Eberhardt (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-0ct201 - 6 (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
warrnt/chébk be issued to him/her in the $ 18A7' .(3)
Signed: (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued,
(5 -Su scribed and „sworn to before me this 5 1-- \ day ofith 20 .
144411
NOT/AaY PUBLIC
Notary Public State of Arizona
My corn s on expires: Maricopa FRenee Fuglel County
5/& / My Cornallsweb Expleas ob/20/2019 (seal)
Warrant/Check Number 000000370007497
(If known))
Original Date of Issue 05-Oct-2016
(If known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
El For Services or Goods furnished
El Treasurer's refund/payment
Other: Victim Compensation: VC2015000403-1