Extracted text (via pymupdf_layout)
2122 characters
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. eftrari#K, ADS/OVCA I &CoAi (1), being first sworn, upon oath deposes and says: ame/Claimant 014 56Ant.-Fof2 co r. On or about 1741J1US IF iZo r ‘date, 1(2) a warrant/check was issued to the above named perstNentity 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 $ It 2? 3 9 9 5- .(3) Signed r: apv—vnAt) k)A6 LIV-L (4) (5)5ubkribBc and swor ELI] efore me this 1 1---V-k--V\ day of Nov-eMoe( 20 ff :2<c OTARY PUBLIC TATJANA MARIE FOSDICK Notary Put*. Slate of Arizona My commission expires: MARICOPA COUNTY Dcr..x,r-\\Dc \c) My November Commission 19, Expires 2019 (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 37000 7 LH know91(11. Original Date of Issue Z-2-g-- (if known) (7) Reason for original issue of Warrant/Check (8): CI Payroll For Services or Goods furnished CLEP --1,0PERVISORS /1/==t-'itn, COUNTY 111 Other: S:\PROCESSES\Warrants - Duplicate or Stale \02 Forms\Schools\Schools-Warrants Checks notice of clairmdoc Revised June 2015 A.R.S. 11-632 ai 15-'199 GC4DIV Plan. Build. Deliver. To Whom It May Concern: This letter is to verify Samantha Koslovich as an official representative of GCON, Inc. and to verify that she is an authorized signer. Sincerely, irnA, GCON, INC 1606 W. Whispering Wind Drive I Phoenix, AZ 85085 I 623.581.6300 (P) I 623.581.3302 (F) I GCONInc.com I AZ ROC 182765