STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3700915802 - SCHOOL HEALTH CORPORATION.PDF

Schools Affidlavit/Claim Form 
Application for a Duplicate Warrant/Check (defl11lt1011s arn on page 2)
STATE OF ARIZONA 
Note: Numbers on this form correspond to numbers on the 
COUNTY OF MARICOPA 
Instruction sheet which is page 2 of this form. 
,ʑ\OD\ ʒf-1-ii d>vp?Va:hb
'.U), being first sworn, upon oath deposes and says:
ame/Clalmant 
On or about Dcfvb.e.v ?? . ;)()';)6' (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 
warra
:
tz be issued to him/her in the s 111 of $_q_,_,_l--=
S''-'-,_C/_,__
'3 _____ .(3)
----Signe . 
144 , 
1lne5S}1 
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-
---
-
My commission expires: 
J../!'-{ /1.., 1
OFFICIAL SEAL 
ANDREW WLEZEN 
NOTARY PUBLIC, STATE OF ILLINOIS 
MY COMMISSION EXPIRES: 03/14/2027 
........,, 
(seal) 
Note; Please attach a copy of the wa1rant/checl< if available and/or any other 
evidence that a warrant/check was originally issued. 
Warrant/Check Number 
3,  WI 16"'6°0d-
(If known) (6) 
Original Date of Issue 
()c,wb ev -a-d ')<)€
(if known) 17) 
Reason for original issue of Warrant/Check (8):
D Payroll 
ʓ For Services or Goods furnished _ ___,
\j
'-'U.ʔ{iʕ°ChʖQʗS=eʘd
-ʙfuJʚʛ6ʜ
dʝ.Sʞ--
D Other: _______________________ _ 
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc 
Revised June 2015 
A.R,S. 11-632 & 15-999