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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.
r-1-114 (1), being first sworn, upon oath deposes and says:
ame aiman
On or about ig, 2.po (date)(2) a warrant/check was issued to the
above named , rson/ehtity 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 issued to hirnfh in the sum of $ 9 (4 350 .(3)
Signed: (4)
(5) Subscribed and sworn to before me this i 'day of 20
if9-tlet
NOTARY PUBLIC
JOYCE C. COUNCIL
Notary Public. Slate ("Arizona
My c mission expires: MARICOPA COUNTY
/ My September Commission 11.2021 Expires (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 ,01 4 . 7511 6266z
(if known) (6)
Original Date of Issue isi M9
(if known) (7) 1/
8 2019
Reasoyi for original issue of Warrant/Check (8):
g Payroll
0 For Services or Goods furnished
0 Other:
S: \ PROCESSES \Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc
Revised June 2015 A.R.S. 11-632 & 15-999