STAMPED & REDACTED- JAIME COLE.PDF
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Schools Affidavit/Claim Form MAR COPA COUNTY Application for a Duplicate Warrant/Check (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. _D_r_. J_ a_i_m_e_C_o_le ______ (1 ), being first sworn, upon oath deposes and says: Name/Claimant On or about 12/06/2024 (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 applicant requests that a replacement warrant/check be issued to him/her in the sum of $_8_3_.0_5 _______ . (3) Signed: (4) Print name: (required) _D_r_. J_a_i_m_e_C_o_le ____________ _ My commission expires: 04.hl\'l-o'l.-1 INDRI NHAM Notary Public • Arizona Maricopa County Commission # 643059 My Comm. Expires Feb 18, 2027 Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. Warrant/Check Number 3700828489 (if known) (6) Orig ina l D ate of Issue 12/06/2024 (if known) (7) Reason for original issue of Warrant/Check (8): □Payrol l □For Services or Goods furnished _____________ _ Other: Travel Reimbursem ent S:\FinanceDesk\Schools-Warrants Checks notice of claim.docx Revised May 2025 A.R.S. 11-632 & 15-999