STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3010205281 - KENDRA HALCOMB.PDF
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Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: !Kl Duplicate 01 ,, Stale-Dated (definitions are on page 2) STATE OF ARIZONA COUNTY OF MARICOPA Note: Numbers on this form correspond to numbers on the Instruction sheet which is page 2 of this form. _K_e_n_d_r_a_H_a_lc_o_m_b _____ (l), being first sworn, upon oath deposes and says: Name/Claimant On or about 2/19/25 (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 aõer 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 • 40.00 ________ .(3) Print nam Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscribed and sworn to before me this'\.ö day÷ _9--1g, NOTARY PUBLIC My commission expires: ,o- °&-C\-a--o.,._'\ ' Lj "----- ' - NOTARYPUBUC-ARJZONA MARICOPA COUNTY & ANNETTE GILLESPIE COMMISSION #668841 MY COMMISSION EXPIRES ---·- OCTOBER 29, 2027 Warrant/Check Number 000003010205281 'if known\ 16\ Original Date of Issue 2/19/25 !if known\ /7\ Reason for original issue of Warrant/Check (8): □Payroll 2cPJ... (seal) □For Services or Goods furnished, _______________ _ □Treasurer's refund/payment ________________ _ i. other: Victim Compensation re: reissue check S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\100518 Warrants Checks notice of claim.doc Revised 100518 A.R.S. 11-632 & 11-644