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Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 Duplicate or al Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to COUNTY OF MARICOPA numbers on the Instruction sheet which is bade 2 of this form. STAPLES (1), being first sworn, upon oath deposes and says: Nameiciaimant On or about 20-Nov-2012 (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 is 6,t9ihim/her in the sum of $ 3,236.92 .(3) Signed: (4) Note: Please atta0 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 1C3111k day of SeNo-\- 20 \ J. oaq,6 tH NOTARY PUBLIC d 05 0-X)rc. “Th\--5,6AD My c mmiss'on expires: LcAy-cil rrn% (seal) Warrant/Check Number 778757 (If known) (6) Original Date of Issue 20-Nov-2012 NOTARY PUBLIC (If known) (7) Gniimis On i RINI8 *412: Reason for original issue of Warrant/Check (8): 0 Payroll 0 For Services or Goods furnished Treasurer's refund/payment for reduced taxes LI Other: