STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3010207708 - EIDA RAMOS.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: 
Duplicate or 7 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 
Note: Numbers on this form correspond to 
COUNTY OF MARICOPA 
numbers on the Instruction sheet which Is 
Daae 2 of this form. 
_Ei=d=a"""Racccm o_s ______ Ɍ(1), being first sworn, upon oath deposes and says: 
Name/Claimant 
On or about 20-Mar-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 tg, him/her (n he sum of$. t..( ! !o • qJ
.(3) 
t11 1-
.. frJ , ,( 1 
Signed: N1 
·ɍ ,Ɏ 1 [-{ ; 
1! 
• 
(4) 
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----..... , ............ - -- 
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
Reason for original issue of Warrant/Check (8): 
D Payroll 
VERONICA RAZO 
Noia<y Puhl6 • Stalo of Anzona 
MARICOPA COUNTY 
Cotnmlselon # 640092 
7xplreo Oeoember 14, me
(seal) 
D For Services or Goods furnished. ______________ _ 
D Treasurer's refund/payment _______________ _ 
0 Other: Never received check - Req #2 - VC2059058-1
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