STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3010203538 - GABRIEL LUGO.PDF

'\fll lie tion for i' iuplicate or Stale-Dated Warrant/Check 
Affidavit/Clain, Form 
This application is for: 
Duplicate.l'or . 
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. 
_G_a_b_r_ie_l_L_ugo _______ (1), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about 1/27/2025 
(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 applica t requests that a replacement 
er in the sum of $_17, '+---,'':--1-:-----t'-+----·<3)
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SigneŁ\--1/-➔==---__:_-,L-=---:__:_----1,------.:::,&-,c....::...ł____,--+-____::,,J\4) 
Print n .me: (required) _L..,r::;,
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"'"Ń '--'\o
=--1'_"'_, -=e=---'--'+-'--'--"'-'-'-.c..__-'---'[ ... • /"-'-"'J"""ń+'<lJJ--------­
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
(Ņ
d
-
and sworn to before me this 
. . -:s-
NOTARY PUBLIC 
My commission expires: 
cG  iç _. è 
C,_,,..., 
-. 
day of ņ U/(\ua,,y 2020. 
@
BradYoung 
Notary Public
Maricopa c-%Arlzo,,
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. 
Warrant/Check Number 000003010203538 
(if known) /61 
Original Date of Issue 
/if known l /71 
1/27/2025 
Reason for original issue of Warrant/Check (8): 
D Payroll 
D For Services or Goods furnished _______________ _ 
□Treasurer's refund/payment ________________ _
Ň Other: 1948029-1 rqst 7
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