STAMPED AND REDACTED FOR AGENDA ATTACHMENT - 3010212943 - PARIS OCONNELL.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/ Claim Form 
This application is for: 0 Duplicate or O Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 
COUNTY OF MARICOPA 
Nole: Numbers on this form correspond lo numbers on the
Instruction sheet which is page 2 of !his form. 
'-'Pa""ri=-•O
:::..'C
"'o"'n"'ne:::.11 _________ (,l), being first sworn, upon oath deposes and
Name/Claimant 
On or about May20,202s 
(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 $""1,2"'1""'s.,, s3:__ ________ ,.(3)
Signed: Yk 
(4) 
Print name: (required) -,ɥ-'"'-'c'-'1----'-15"---_lt--=t"'-l"\"-lf'"""CC:.ɦ\"'\-------------­
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
My commission ɧɨpires:
1u "1l ¦- za U 
Warrant/Check Number
if known 6 
Original Date of Issue
if known 7 
3010212943 
05-20-2025
Reason for original issue of Warrant/Check (8):
D Payroll
MARSHALL SHELTON 
Notary Public. Arizona 
Maricopa County 
My Commission Expires 
October 8, 2026 
Commission ·"f- 635159 
eal) 
D For Services or Goods furnished _______________ _
D Treasurer's refund/payment ________________ _
0 Other: Victim Compensation Claim: 2011518-1 Req 2 and 3
C:\Users\michies\Desktop\Duplicate or Stille Dated Warrant Affidavit-Oalm Form.doc 
Revised 100518 
A.R.S. 11-632 & 11·644