STAMPED AND REDACTED 3010219834 -PHOENIX CHILDRENS HOSPITAL.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: El Duplicate or D 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 
oaae 2 of this form. 
Phoenix Children's Hospital (1), being first sworn, upon oath deposes and says:
NameJClalmam 
On or about 15-Aug-2025
{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, m: 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 issued to him/her in the sum of $79,020.00
.(3) 
Signed: ID\7&:eiR 1rl\ 
(4) 
Note: Please attach a copy of the wa,rant/check If available and/or any other
evidence that a warrant/check was orlglnally Issued. 
My commission expires: 
lR-13, i!P2-1 
Warrant/Check Number 
If known 6 
Original Date of Issue 
If known 7 
3010219834 
Reason for original Issue of Warrant/Check (8): 
• 
LORIBZUNK 
NDTNIY-PIIINJO-N4'0Ni\ 
MN\!001\\1:CXlffi 
-·­
MY'OOMliUlelONDPIREB 
MEtJ.11111 
(seal) 
D Payroll 
is/ For Seivices or Goods furnished, _____________ _
D Treasurer's refund/payment _______________ _
D Other: ______________________ _