STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3700923625 - CINDY WEBB.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (definitions are 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. 
_CƾIN=D=Y=W=E=B_B _______ (1), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about 
JI/-µ::; /Wl-½ 
(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, ru: 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 $_....cl_'-f.:....'i(_, 1.h_-_____ , (3) 
y commission expires: 
'2!' 
io 8 
---i,._l lƿ_day of \xc.ALM.bc.r 20 '?. S . 
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 Number 
if known 6 
Original Date of Issue 
if known 7 
Reason for original issue of Warrant/Check (8): 
D Payroll 
Iii For Services or Goods furnished PAYROLL 
---------------
□Other: PAYROLL
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks nokce of dalm.doc 
Revised June 2015 
A.R,S. 11-632 & 15-999