DUPLICATE WARRANTS-FINANCE 1.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 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.
Patrick E. McGillicuddy (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 19-Jun -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 to him/her in the sum of $ 8,160.00 .(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 (carn-tp sw before me this c- day of -TA 20
NOTARY PUBI7IC -,
KIMBERLY SZELIGA
My commission expires: Notary Public - Arizona
At 9C.T7 My Comm. Maricopa Expires County Nov 20.2017 (seal)
AMMEWIIIMI
Warrant/Check Number 340031024
(if known) (6)
Original Date of Issue 19-Jun-2014
(if known) (7)
Reason for original issue of Warrant/Check (8): v
E
0 Payroll -APP
For Services or Goods furnished May 2014 DAT
0 Treasurer's refund/payment lirOMBff SOR
MAHICOPA _ ___---- COUN TY
0 Other: