STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3700882851 - VOSS LIGHTING.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check 
( definitions are on page 2) 
MARCOPJ\ 
C()UNTY 
ST ATE OF ARIZONA 
Note: Numbers on this form correspond to numbers on the 
COUNTY OF MARICOPA 
Instruction sheet whicl1 is page 2 of this form. 
J/f)js_q/,f/»f 
(1 ), being first sworn, upon oath deposes and says: 
Narne/Clainwn\ 
On or about -(1k,p,/J!X)S 
(date) (2) a warrant/check was issued to the c1bove .. namecl
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, Qt 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 
warra11t/cl1t?be issued 
him/her in the sum of s':lj_l/5, oO
. (3) 
Signed: ✓,(}_(lf:!41,J o -,4/l&c-rv 
.. (4) 
(5) Subscribed and sworn to before me this ˾ O 
day of˿ 20̀>.
-
NOTARY PUBU 
My cornrnission expires: 
Jehcu"c'f I t-:.'l.__,_7_ 
Stale of Nebraska -General Nola,y 
JAMES C MCCLURE 
My Commission Expires 
Fabrua,y 13, 2027
(seal) 
Note: Please attach a copy of the warrant/check if available and/or any other evidence 
that a warrant/check was originally issued. 
-Warrant/Check Nu1nbe,f- ;-́_:7 -
{) ()6 ,
1 
<1-r
j 
------- -- -- - --- -- -- -
(1f known) (Ql_ 
J 
Q_ Z) .,<, O 0 
-Origill̂ll Date oflssue
, I 
___ (If known) (72 ___ 
_ __ _f)_h (2jf'f-_2J)'J: S ___ ., __ ̃- _ __ _ __ __ __ ___ _ __ 
Reason for original issue of Warrant/Check (8): 
D Payroll 
[k(' For Services or Goods furnished___cudec ,ft 55) 7f//j)_SI) •• DO 
D Other: 
s:\F!nanc(·.iDcsk\Schoo!s-Warrant5 Ct1ecks noUce of dalm,docx 
Revised May 2025 
A.R.S. 11-632 c\ 15-999