STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3010217619 - MIRIAM ACOSTA VEGA.PDF
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Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim form This application is for: !!!I Duplicate or D Stale-Dated (definitions are on page 2) STA TE OF ARIZONA Note: Numbers on this form correspond to numbers on the COUNTY OF MARICOPA Instruction sheet which is page 2 of this form. Miriam Mayte Acosta Vega (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 7/18/2025 (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, 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 warrant/check be issued to him/her in the sum of $._4_8_._4_0 ________ .(3) Signed:--'=Ė".!:>=· ė='·=-· ______________ (4) --;/ Print name: (required) t"/1\•v•,:v:1 P1,1uJ• 1:1,c-,+•·· VĘ-q , J Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. NOTARY PUBLIC Warrant/Check Number if known 6 Original Date of Issue if known 7 3010217619 7/18/2025 Reason for original issue of Warrant/Check (8): D Payroll VERONICA RAZO Notary Publo • Stale ol Arimoll! MARICOPA COUNTY Commi"8/on # 840692 e,p1roo Doeombor 14, 2026 (seal) □For Services or Goods furnished. _______________ _ □Treasurer's refund/payment ________________ _ iiil other: VC2083376-1-rqst5 S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claitn.doc Revised 100518 A.R.S. 11-632 & 11-644