STAMPED AND REDACTED - 3010225182 - VALERIE GARCIA.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: D Duplicate or IX! 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 
Daile 2 of this form. 
-v...,.a=leįri=e""G""'a_rc_i_a _____ (l), being first sworn, upon oath deposes and says:
Name/Cla,mant 
On or about 10/27 /25 
(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/ch
,
. k be issued to him/her in the sİm of $_2-'-, 0_3-'----'--8_.0_0 ______ .(3)
Signed: l  6i  
(4) 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
ubscribed and swo to before me this 3,.-J_._ day ofkhY\JOM 20.:zJa.. 
' 
Warrant/Check Number 
3010225182
if known 6 
Original Date of Issue 
1 0/27 /25 
if known 7 
Reason for original issue of Warrant/Check (8): 
□Payroll
•ALEXANDRA MONROY
Notary PublC - State of Arizona
MARICOPA COUNTY 
Commission# 655217 
e,pires July 29, 2027 
(seal) 
□For Services or Goods furnished ______________ _
□Treasurer's refund/payment-------------,-------
0 Other: 211164O-1-rqst2 - (,A.)( -r.0 J. 1c, 'I= C/(of / ı 0 )Cf a -C t;,,.J(\\ ':{ Ar'>ro r Ile y 
fvAQ cJ/9