REALTY TRANSITION COMPANY LLC - #963814 - REDACTED.PDF

Application for a Duplicate or Stale-Dated Warrant/Check 
Affidavit/Claim Form 
This application is for: D Duplicate or  Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 
COUNJl,OF MARICOPA 
Note: Numbers on this form correspond to numbers on the 
Instruction sheet which is page 2 of this form. 
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. _(1), being first sworn, upon oath deposes and says:
Name/Claimant 
/ 
On or about 
/O; r1-/2,3 
(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, Qt 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 $ __ í_D_Cf_,_'-f_( ____ .(3)
Signed: 
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ï 
(4) 
Print name: ( required) MI CH '1 E. L 
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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. 
(5) Subscribed and sworn to before me this 
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 day ofðñò
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NOTARY PUBLIC 
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My commission expires: 
'i Ju I z.0;1.2 
Warrant/Check Number 
if known 
6 
Original Date of Issue 
if known 
7 
JO 
Reason for original issue of Warrant/Check (8): 
□Payroll
KIM LEE BOURQUE 
NOTARY PUBLIC -ARIZONA 
MARICOPA COUNTY 
COMMISSION # 645331 
MY COMMISSION EXPIRES 
APRIL 06, 2027 
----------
(seal) 
□For Services or Goods furnished _______________ _
õreasurer's refund/payment-------,------------
□Other: _______________________ _
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 
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