DUPLICATE WARRANTS PAYROLL.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or D 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
oacie 2 of this form.
Cardinal Health - Pharmacy (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 28- May-04 2 1 (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 a shown is due and owing, and the applicant requests that a replacement
warrant/check be ' s 1 ;:him/her in the sum of $28371.32 , .(3)
Signed: v --17- • , . , / ., ,.,,•!.(4,( (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) Subs ribed and sworn to before me this day of Jo [y 20 .
NOTARY PUBLIC TOM E. BURNS
Notary Public, State of Ohio
My commission expires: My CommIston Expires 04-25-2(ro"
- (seal)
Warrant/Check Number 340028921
(if known) (6)
Original Date of Issue 28-May-2014
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
0 For Services or Goods furnished in May 2014
LI Treasurer's refund/payment PPROY 11)1
El Other:

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 12 Duplicate or 0 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
page 2 of this form.
IBM SERVICES (1), being first sworn, upon oath deposes and says:
—Fgme/Claimant
On or about I 1-Jul-2014 (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 o him/her in the sum of $27,500.00 .(3)
Signed: 41(.064J (4)
Note: Please attach a copy" of the warrant/check if available and/or any other
evidence that a warrant/cgeck was originally issued.
to before Uel me this L l IIS uchlYY uofi 20 .
MONA JANNAT
Notary Publlc - Arizona
My commission expires: My Mallcopa Commission County Expires
1 .?_• 2o( September 13, 2016 (seal)
Warrant/Check Number 350000705
(if known) (6)
Original Date of Issue 11-Jul-2014
(if known) (7)
Reason for original issue of Warrant/Check (8):
111 Payroll
For Services or Goods furnished during the month of May and June, 2014
El Treasurer's refund/payment
APPROVED
Other: