STAMPED AND REDACTED - 3010234354 - AMERICAN INDIAN VETERANS MEMORIAL ORGANIZATION.00.PDF

Application for a Duplicate or Stale Dated 
Warrant/check Affidavit/Claim Form 
This application Is for I I I Oupllcate or D Stale-Dated (definitions are on page 2)
------------------ 
ST ATE OF ARIZONA 
COUNTY OF MARICOPA 
Note: Numbers on this form correspond to the numbers 
on the Instruction sheet which is page 2 of this form 
AMERICAN INDIAN VETERANS MEMORIAL ORGANIZATION (1 ), being first sworn, upon oath deposes and says: 
Name/Claimant 
on or about 19-FEB-2026 
(date) (2) a warrant/check was issued to the above named 
person/entity in the amount 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 issuesʟ hi /h r in the f  of$ 5,000.00
. (3) 
Signed:,_J""-'...,..""-..... -rw
::;,-
:;ʠ=ʡ...,,....---------<4) 
Print Name: (required) _....J.....,..IW-''--.......,""'"=-.......,=-----------
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 \ct 
day of (Yluc, h
NOT1Rf 
PuFEGH
0'< 
MA commission expires: 
\?ri\ ld,101.9 
Warrant/Check Number 
{if known) {6) 
Original Date of Issue 
{If known) (7) 
---NC!:":'UOA':"LPSQIMROSNTMUA';'!;'G":1AKM 
Notary Public, State of Arizona 
Maricopa County 
Commission# 682662 
My Commission Expires 
A ril 1 a, 2029 
3010234354 
19-FEB-2026
Reason for original issue of Warrant/Check (8): 
20.&. 
(seal) 
0 Payroll ________________________ _ 
□For Services or Goods furnished __________________ _
□Treasurer's refund/payment ___________________ _
0 Other: D180-OFFICE OF OUDGET & flNANCE-FUND 249-GAX1D 20.11952 --FMYN 12% Tr11>al Gaming Grant CY25 FY26
S:\PROCESSES\Warrants • Duplicate or Stale\02 Forms\Current Cl aim Form\ 100518 Warrants Checks notice of claim.doc Revised 
100518 
A.RS.11-632& 11-644