Extracted text (via ocr_local)
2813 characters
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: oO Duplicate or [Wstale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Leng Yres fr (1), being first sworn, upon oath deposes and says:
Name/Claimant \
On or about Ue \2 | (date)(2) a warrant/check was issued to the
above named ere 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 $ Y lc 2D q O .(3)
Signed: Qrece Vues {orm (4)
Print name: (required) “_|_ ¢@me_ Yeston
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 LioKe day of Atlas, 20 ) Om
Wute &) Bog
NOTARY PUBLIC
DESIDERIA Q. RAMIREZ
Notary Public - State of Arizona
"ort ied expires: MARICOPA COUNTY
_QODsS Expires April 9, 2025 seal)
Warrant/Check Number , _
(if known) (6) S0\008 6 Zor
Original Date of Issue
(if known) (7) \\2v \e4
Reason for original issue of Warrant/Check (8):
O Payroll
by For Services or Goods furnished
OO Treasurer's refund/payment
OO 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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STALE DATED
Ohyeb/e0ee Do Not Re-deposit
This is a LEGAL COPY
of your check. You can
use it the same way
you would use the
original check
+ pt.2nt224
RETURN REASON -G
STALE DATED Four Thousand Six Hundred Thirty And 90/400 Dollars
j , $4,630.90
: PAY TO THE ORDER OF ; : AMOUNT
PRESTON FUNERAL HOME : few Lda
Void Aflar (CHAIRMAN
ol 365 Days gia
: aE FINANCIAL OFFICER
038
000138 W9TRIZ28
PRESTON FUNERAL HOME INC
ITEMS ENCLOSED:
PAGE 1 oF 1 ACCOUNT CHARGED XXXXXX0278 DATE: 01-28-2022
REASON FOR NON-PAYMENT SEQUENCE # AMOUNT
DEPOSITORY ACCOUNT NUMBER: XXXXXX0278
YOUR ACCOUNT HAS BEEN CHARGED FOR THE FOLLOWING PAPER ITEM(S) RETURNED UNPAID.
Stale Dated 3331373733 4,630.90
TOTAL CHARGES FOR PAPER RETURNS 4,630.90
TOTAL CHARGES FOR PAPER RETURNS 4,630.90
TOTAL FEES 12.00
SHOULD YOU HAVE ANY QUESTIONS OR REQUIRE ADDITIONAL INFORMATION,
PHONE NUMBER THAT IS LISTED ON YOUR BANK STATSMENT.
PLEASE CALL THE ~