STAMPED AND REDACTED - 3700939645 - AMERICAN REFRIGERATION SUPPLIES.PDF
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Schools Affidavit/Claim Form Application for a Duplicate Warrant/Check (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. AMERICAN REFRIGERATION SUPPLIES (1), being first sworn, upon oath deposes and says: Name/Claimant On or about I fil/ Lb (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__.0f-c$- 6._ .. _3_5_.4_8 ________ .(3) 7 /. --/ ✓ Signed: ' ȓ' ) L 7""° -:, " r·/ - ;_,, (4) (5) Subscribed and sworn to before me this !GI day of fr,i), '1 \ I /t_p;tz/t•/;:;f. zc/ __ , NOTARY PUBLIC/ .. . My commission expires: r::fL. 11-'9 r 1,67, 1 @ Notary Public State of Arizona Maricopa County •• • Jessica Ann Bauer ... ,,,.. My CommlUl«l E,:s,lrU 2/28/2027 Commlulon Number $4300 Ì--·- _20Ȕ. (seal) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Warrant/Check Number 3700939645 j (if known) (§t_ --------------------j Original Date of Issue 1/27/2026 L__ __ ""lf-'-'knol'l_nj-'-7'-'-----'-- _____________________ _ Reason for original issue of Warrant/Check (8): D Payroll ȕ For Services or Goods furnished PO 2026063, INV 31323115 o Other: PO 2026063, INV 31323115 S:\PROCESSES\Warrants - Dupllcate or Stale\02 forms\Schools\Schools·Warrants Checks notice of claim.doc Revised June 2015 A,R,5, 11-632 & 15-999