STAMPED AND REDACTED - 3700942493 - GUITAR CENTER STORES LLC.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (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. 
&u.i ta.r Ce nt-e, .S"io(e:s., l.-,c., (1), being first sworn, upon oath deposes and says: 
NemelCiaimant 
On or about 
;iJs/.,,o.,;,,1,,, 
(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, QI: 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 $ __ .;i.
___,_1 _&,_J_7_,-'(p'--c),'-'----·<3) 
Signed: _ _.....( Wu.&1.nt/A"""""""""'
JA..fl_=.:;;D::...U""...,L-------'<4) 
(5) Subscribed and sworn to before me this
u(\)oµ 
NOTARY PUBLIC
My ˳ission expires: 
• \ l ,?f}.9-le 
t.3 
dayof Hay
(seal) 
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 
, 37000L/-;J/.('73 
(If knownl 161 
Original Date of Issue 
.,./s;.:. od.\,,
/Jf known l 171 
Reason for original issue of Warrant/Check (8): 
□ Payroll 
□For Services or Goods furnished ______________ _
□Other: ______________________ _
S:\PROCESSES\Warrants - Dupl!cate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of dalm,doc 
Revised June 2015 
A,R,S, 11-632 & 15·999