STAMPED AND REDACTED - 3700955170 - AMERICAN REFRIGERATION SUPPLIES.PDF

Schools Affidavit/Claim form 
Application for a Duplicate Warrant/Check (definll!ons 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. 
AmerJ C{.trJ l<efrj;,ra,ilo/\ 
(1), being first sworn, upon oath deposes and says: 
Name , a1man 'S ppl 1, 
S 
On or about fs /JJo,96 
(date)(2) a warrant/check was Issued toJhe
above named person/entity in the amount as stated below, 
Such warrant/check was 
either never receive□ or was subsequently inadvertently lost or destroyed and there is 
no reasonable probability of its being found or presented for payment, Q!'. it was not 
presented for payment within one year after the date of issuance. 
Therefore, under penalty of perjL1ry, claimant hereby affirms that this claim is correct 
and the amount shown is due and owing, and the applicant requests that a replacement 
Ɏarr
.
ant/checkɏ
. 
is u(-:i:
·
0
· 
;ɐ
.
er iɑɒ
. 
of$ 9,, 91l, • 8 0 __ .(3) 
.Signed: -C)_ x;>/  ɓ--------(4)
(5)' Subscribed and sworn to before me this _·"'=:5 __ day of VV\ 01.y
-------,v_J /
0·0,Zf ., 
NOJ,:AɔY PUBLIC 
My COllJmission expires: 
UUJJ!i /7,01,1 __ 
, 
Notary Public State of Arizona 
, <i Maricopa 
County
i 
J_esslca Ann Bauer 
• 
My Cornm:nlQf'I Expitu 2128/2027 
Comminl<in Number 6'3690 
(seal) 
ih========s==================-
Note: Please attach a copy of the warrant/check if available and/or any other 
evidence that a warrant/check was originally issued. 
Reason for original issue of Warrant/Check (8): 
□Payroll
[rY"For Services or Goods furnished--------------
□Other: -----
S:\PROCESSES\Warrants - Dupllcate or Stale\02 Forms\Sd1ools\Schools}Warrants Checks notice of dalm.doc 
Revised June 2015 
A.R.S. 11-632 & 15-999