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-1k-roplication for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 Duplicate or Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to COUNTY OF MARICOPA numbers on the Instruction sheet which is page 2 of this form. Silvia Gallo MA LPC Name/Claimant Ongpr about 29-Nov-2018 (date)(2) a warrant/check was issued to the ab6k named person/entity in the amount as stated below. Such warrant/check was Eaffer never received or was subsequently inadvertently lost or destroyed and there is iildeasonable probability of its being found or presented for payment, or it was not aented for payment within one year after the date of issuance. • 0 refore, under penalty of perjury, claimant hereby affirms that this claim is correct the amount shown is due and owing, and the applicant requests that a replacement al Y wErant/check be issued to him/her in the sum of $ 577-50 .(3) o / _ Signed: doe_a_..1 (4) Note: Plea /attach a copy of the warrant/check if available and/or any other evidence that a warranVcheck was originally issued. (5) Subscribed and sworn to before me this q day of );thvIctyy 20 `).0 . NOTARY P JONATHAN JACOBS Notary Public- State of Arizona MARICOPA COUNTY Commission #572892 Expires September 24, 2023 My commission expires: o9RIE/ao/a3 (seal) Warrant/Check Number (if known) (6) 3010020665 Original Date of Issue (if known) (7) 29-Nov-2018 Reason for original issue of Warrant/Check (8): El Payroll LI For Services or Goods furnished El Treasurer's refund/payment Other: Victim Compensation Check: 1743650-1 (REQ#2) EufN 06oc 1915 -065eck Vla, -Sub 0933cc+ I - CNA)ci, -0141(P (1), being first sworn, upon oath deposes and says: