062718 STALE DATED WARRANTS 1.PDF

Application for a Duplicate or Stale-Dated Warrant/Check RECAVFD
Affidavit/Claim Form MAY 2 1 2018
This application is for: 0 Duplicate or It/Stale-Dated (definiebBNIMPIRTPW-44UPERVISORS MARICOPA csOUNTY
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
pace 2 of this form.
STOei (1), being first sworn, upon oath
d6\05%giV9altays:
On or about-bS_ct:ivI bE,e_ Z i 2D ( (date) )(2) (2) a warrant/check was issued
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 issu to him/iheyin the sum of $ S66.96 .(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 /..4" day of friet,y 20 i4?.
NOTARY PUBLIC
Notmy itara Pudic Buoltay klmea
My commission expires: My CC•1111WIN1Orl MmicoPm County Expires
JmN it Nat (seal)
Warrant/Check Number s o 139
(if known) (6)
Original Date of Issue I aol,
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
El For Services or Goods furnished
If/Treasurer's refund/payment 9,0110 Pc-cnEitxt, tV TN'
PAiqvNEWC
C:\Users\tkuder\AppData \Local\Microsoft\Windows\INetCache\Content.Outlook\FY2Q7XIO\Warrants Checks Notice of Claim.docx
Revised and updated: April 2014 A.R.S. 11-632 81. 11-644