STAMPED AND REDACTED - FOR AGENDA ATTACHMENT - 3700887590 - COX COMMUNICATIONS.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check 
(definiUons ate on page 2) 
l
MARlCOPA 
 COUNTY 
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, 
Cox Communlcatloris Arizona, LLC (l ), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about 07/22/2025 
(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, m: It was not presented for payment within one year after 
the date of issuance. 
Therefore, under penalty of perJuiy, claimant hereby affirms that ϭhis 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$ 28,220.71 
(3) 
Signed: 4 \JJ.1.M r., :-,.< -,..
(4) 
' 
c:.) 
Print name: (required) Jennifer Velasquez 
(5) Subscribed and sworn to before me this ,;).s::l;iay of.» 0k1'l'lblf20.2:5:.
Q OX\ Q R \& ϮVA \.k,.(Lp 
NOTARY PUBLIC 
' 
Ashlea Dawn Bruce
NOTARYPUBLfC 
MY. 
1
om
ϯ
lssion expires: 
;Q a o10&£0 
CommonweijHh of Virginia 
Reg. # 8032358 
My Commission 'Expires 2128/2026 
(seal) 
Note: Please attach a copy of the warrant/check if available and/or any other evidence 
that a warrant/check was originally fssued. 
Warrant/Check Number 
3700887590
(If known) (6) 
Original Date of Issue 
(if known) (71 
07/22/2025 
Reason for original issue of Warrant/Check (8): 
□Payroll
' 
Iii For Services or Goods furnished Cox Communications Services
D Other:
S:\AnanceDesk\Schools·Warronts Ched<s notlce of dalm.doe< 
Revised May 2025 
A.R.S. 11·632 & 15·999