STAMPED AND REDACTED - 3700868379 - SLICK CITY PEORIA.PDF
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Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/ Claim Form This application is for: Iii Duplicate or D Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond lo numbers on the Instruction sheet which Is page 2 of this form. _s ...,u "" C "'K ""'C ""l=TY=P_E_O....:.R_IA_L.:..LC _______ ,(1), being first sworn, upon oath deposes and says: Name/Claimant On or about o51o712o25 (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, gr 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 bʎ issued to him/her in the sum of $-_6_28_0_.7_2 ________ .(3) Signed:ʏʐ ( (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was orlginal/y Issued. ubscribed and sworn to before me this Jf'J; -141 day of @bt]A•'--1 201J2. -qr My commission, ij xr1lres: MC\yc,\t) 28, rJlJb Warrant/Check Number 3700868379 if known 6 Original Date of Issue 0510712025 if known 7 Reason for original issue of Warrant/Check (8): D Payroll KYLIE WHITEHOUSE Not1ry Pub lie • Arl1on1 Iar1cotia County Commlnlon I 664),t M.y COfT\m, bPtrn ,w 29, 2028 (seal) Ill For Services or Goods furnished, ______________ _ o Treasurer's refund/payment _______________ _ D Other: ____________________ _ S:\PROCESSES\Warrants • Duplicate or Stalc\02 Forms\Warrants Checks notice of claim • copy.doc Revised Aprll 2015 A.R.S. 11-632 & 11-6'14