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Application for a Duplicate or Stale-Dated f.eit4gU Affidavit/Claim Form JAN 18 2019 . z This application is for: El Duplicate or 0 Stale-DRY 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. PmES,TiA nci (1), being first sworn, upon oath deposes and says: I. On or about Note-rn ck--7)kin (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 issued to him/her in the sum of $,. 3.zag g 19 .(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) Subscribed and sworn to before me this /C/#7 day of triecti--. 20 / . NOTARY PUBLIC KRISTEN LAUREN MEGAN JONES NOTARY PUBLIC REG. #7622807 My commission expires: COMMONWEALTH OF VIRGINIA 2ary,4 311 a I ri MY COMMISSION EXPIRES MAR. 31, 2019 (seal) Warrant/Check (if known) Number (6) '2? -700 / 0-1 60 Original Date of Issue JAN 2\8 2019 (if known) (7) Reason for original issue of Warrant/Check (8): MARICOPA COUNTY III Payroll CSt" For Services or Goods furnished or-4-2.1cd /-adres A24,./7,_ Blamrs Treasurer's refund/payment El Other: S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc Revised April 2015 A.R.S. 11-632 & 11-644 1908 ASSOCIATION DRIVE I RESTON, VIRGINIA 20191 c. 703.860.5000 I DECA.ORG January 10, 2019 ECEiVED B JAN 18 2019 est/ BY: Re: Affidavit/Claim Form for Duplicate Check To Whom It May Concern, This letter is reference to the attached Claim form for a check replacement for Check # 3700114601 written on 11/27/18. Unfortunately, our offices have no record of receiving said check and still show an unpaid balance on the account of $328.19. The claim in reference was completed and signed by Ariel Shumaker and is fully authorized to do so. Should you have any additional questions or concerns please feel free to contact our offices directly. Best Regards, Garret Corbine DECA Retail Operations Manager DECA PREPARES EMERGING LEADERS AND ENTREPRENEURS