STAMPED AND REDACTED - 3010233189 - LINDENWOOD EDUCATION SYSTEM.PDF

MARCOPA 
COUNTY 
Application for a Duplicate or Stale Dated
Warrant/Check Affidavit/Claim Form 
This application Is for lvl Duplicat1 or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA 
COUNTY OF MARICOPA 
Note: Numbers on this form correspond to the numbers 
on the Instruction sheet which is page 2 of this form 
_R_e_n_e_e_A_r_e_ll_a_no 
___ ,__ _________ (1), being first sworn, upon oath deposes and says:
Name/Claimant 
On or about 02-06-2026 
(date) (2) a warrant/check was issued to the above named
person/entity in the amount 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, unde r 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 
r in the sum of $4,000.00 
. (3)
Signed:__,1,ȈȉȊȋȌȍ::.l::::.Ȏu,\ȏȐ,.......2 ______ (4) 
Print Name: (required) _---4,ȑȒȓ4:µȔ1,.µ.:..u.L!:t.:...._ _____ _
Note: Please attach a copy o he warrant/check if available and/or any other evidence that a
warrant/check was originally issued. 
(5) Subscribed and sworn to before me this 17l4- day of ȕȖ'-'Qȗr 
........ , _,· , ____ 20..2.Jp
NOTAR
Y114 (4 
My Kmmission expires:
r; \ l, 2021:: 
Warrant/Check Number 
(if known) (6) 
Original Date of Issue 
(if known) (7) 
Reason for original issue of Warrant/Check (8): 
□Payroll _________________ Ș-șȚ----=--
0 For Services or Goods furnished _C_D_L_T_ra_i_ni_n-=cg..,_p_r_og
=-r_a_m _ _,_/
---'-fl,
--'<-i-N
.-J2
c......,,J.ț;lȜ:J,ȝ. _
□Treasurer's refund/payment ___________________ _
□Other: _________________________ _
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Current Claim Form\ 100518 Warrants Checks notice of cl aim.doc Revised 
100518