112917 STALE DATED WARRANT 4.PDF

Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/Claim Form
This application is for: CJ Duplicate or IX] Stale-Dated (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.
A. A. Bloch (1), being first sworn, upon oath deposes and says:
NamerClamant
On or about February 23, 2016 (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 $140.78 (3)
hal
Signed: Q G (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 day of 20
NOTARY PUBLIC
My commission expires:
(seal)
Warrant/Check Number 1 Checks: #836637 $17.56 #836670 $123.22
ame
eee February 23, 2016
Reason for original issue of Warrant/Check (8):
0 Payroll
(1 For Services or Goods furnished
Notice of Proposed Correction - Real Property #232-36-460
\¢ Treasurer's refund/payment Copy Attached (Owner disabled - refunds to be credited to
parcel as others were, but were not)
D Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy,doc
Revised April 2015 ARS, 11-632 & 11-644