STAMPED AND REDACTED - 3700939646 - AMERICAN REFRIGERATION SUPPLIES.PDF

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/Cla1rnanl
' 
1 
On or about 
I /r.7/Z.t
(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 
(5) Subscribed and sworn to before me this _,__l- _._j __ day of _lc\2_,_['_,_i\,___ 20 21.r
kc:: ;?,;ti_,/ ,::' LC
NOTARY PUBLIC ) 
,_· ... 
· .-... ....................... _ .............. ...., 
Notary Publlo Stat• of Arizona 
My commission expires: 
c}L/Z- 'i!J/1.P UJ 
Maricopa 
County 
Jessica Ann Bauer • 
My Cotrvn!uk>rl Ext)lttt 2/28/2027 
Comm!ulon Numb11r 
843690 
(seal) 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
r_a _ nt/Check N 
. 
u
. 
mber. 
3?00939646
if known 6 
e of Issue 
1 /2 /2026 
ownl.(7,__ _ 
__i __ ? ________
_ _ 
Reason for original issue of Warrant/Check (8): 
D Payroll 
l!!l For Services or Goods furnished PO 2026063, INV 31323117
o Other: PO 2026063, INV 31323117
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schoo!s\Schools-Warrants Checks notice of dairn.doc 
Revised June 2015 
A.R.S. 11-632 & 15·999