DUPLICATE WARRANTS-FINANCE 2.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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
Dacie 2 of this form.
Associated Fire Consultants (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 01 -May-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
k be issu d to Im/her in the sum of $ 4,379.68 .(3)
(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 ior d 14- day of 20 14.
commi/ ANNETTE DUNCAN MUNOZ
My sion expires: NOTARY PUBLIC, ARIZONA
COCHISE COUNTY
Ltibt / gt" My Commission ExpliWa I)
June 11,2018
Warrant/Check Number 340026659
(if known) (6)
Original Date of Issue 01-May-2014
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll APPROVED
For Services or Goods furnished AUN 1 201
O Treasurer's refund/payment
, BOARD OF SUPER V;$ ORE
O Other: MABICOPA COUNTY