STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3700915797 - MAXIM STAFFING SOLUTIONS.PDF

School§ Affidavit/Claim Form 
Application for cl Duplicate Warrant/Check (definitions are Oil page 2) 
STATE OF ARIZONA
aJ., Note: Numbers on this form correspond to numbers on the 
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Instruction sheet wl1ich is page 2 of this form. 
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.-t: , fl :So(t.l{19,ʠing first sworn, upon oath deposes and says:
Name/cTa1manr 
On or about 0:4r)bev ?-?-1 :}0'.}5 (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 cor ect
and the amount shown is due and owing, and the applicant requests that a replacement 
warrant/check be issued to himʡr in the sum of$ 5q. ·)..3'],]5
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Signed: 
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,(3) 
(4) 
(5) Subscribed and sworn to before me. this _LJd__r-:_aay of T)ece,,,,,--t-N' 20 ?/2. -
/.:f'(j2_ 
NOTARY PUBLIC 
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Note: Please attach a copy of the warrant/check if avai!a6!e1 'i11Xtf)or any other 
evidence that a warrant/check was originally issued 
Warrant/Check Number 
/If known) /6) 
Original Date of Issue 
!if known) /7)
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Reason for original issue of Warrant/Check (8): 
D Payroll 
l3l,C For Services or Goods furnlshed __ S
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0 Other: ______________________ _ 
S:\PROCESSES\Warrants - Dupllcate or Stale\02 Forms\Schoo!s\Schools-Warrants Checks notice of claim.doc 
Revised June 2015 
A.R.S. 11-632 & 15°999