060816 DUPLICATE WARRANTS - 5_REDACTED.PDF

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Application for a Duplicate or Stale-Dated Warrant/Check IT3113:117
Affidavit/Claim Form c, oUri
This application is for: I Duplicate or El 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.
Jacqueline Ahumada (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 04/0612016 (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 \A. ,ithin 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 $ 105.00
Signed: ccd4-'
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 AW-.12,14/0"'•,,
P.0'*-0,•RY
My commission expires: =t7 0. =
z , 0 i.zrE (seal)
*Lei
Vv'ci rrci nt/Check Number 22369819 'elf' ICOUNIN'
(if known) (6) 111 1011111 11-‘
Original Date of Issue 04/06/2016
(if known) (7) ____
Reason for original issue of Warrant/Check (8): : • . . f=
M Payroll _ I .
•-•:: 0
El For Services or Goods furnished . Ar g —
D Treasurer's refund/payment 4a111P., ./, , _ .. • - -. E-----
III Other: - - - - li-RLISORS N rv - '.. --'2
Cri
Cr"
April

ME-
Ahurnada,Jacqueline MCVELE
r Paycheck View I [KY-awnings Tae. Deduchons ents pecial Accumulators v Distributions
Name Ahurnacla,Jacqueline Confirmed Check
CheckA Issue Date Earn inos Taxes Deductions Net Pay
22369819 04/06/2016 105.00
Reaularand Overtime Earnino 71-
- Other Earnings -Deductions
ADP Enterprise HR screen print as of: 0511612016 02:55 PM