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NOTICE OF CLAIM STATE OF ARIZONA COUNTY OF MARICOPA Sunrise Water Co, being first sworn, upon oath deposes and says: That on the la day of May 2012, they presented to Maricopa County, for payment, a claim for services rendered or supplies furnished during the month of May 2012, said claim being in the sum of Fourteen and 33/100 dollars, ($14.33) in payment of which the Maricopa County Board Supervisors caused the Warrant Number 766174 to be issued on 5/1/12, drawn on the County's Expense Fund. Claimant further says that although he/she was informed and believes that the above mentioned warrant was regularly issued, the same has never been received, or has been lost. WHEREFORE, daimant requests that the Board of Supervisors issue to him/her a duplicate of said Warrant mber 766174 in the sum of $14.33. Signed: Sub .Akwprpito ar before me this l ir-- day of________ MONIQUE-I) Notary Public LINAS-THOPAAS - Arizona MARICOPA COUNTY Convulsion 241113113 My CtwilmissMn ilah rc Elfir 112 k\csIdatalHnance$ \AP PAY\FORMS107 Affidavit Form Blank.doc Revised March 2007 ms 9/17/2013 9:01:02 AM