STAMPED AND REDACTED - 3700961311 - ELAINE ARNOLDY.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (definitions aro on page 2) 
STA TE OF ARIZONA 
Note: Numbers on this form correspond to numbers on the 
COUNTY OF MARICOPA 
Instruction sheet which is page 2 of this form. 
r.Ja9eɢntt\yl[\O\OJ,J1 
(1), being first sworn, upon oath deposes and says:
On or about L\}l\;Jv 
(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, or it was not 
presented for payment within one year alter 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/chɣ i sue 
o '_\im/her in the sum of $._qes
-'-"--'g_. -'--\ lo ______ .(3) 
Signed: 
f;; 
(4) 
(5) Subscribed and sworn to before me this ----"r;;'-z __J_1_day of _,lɤJ'-l"""1'""?,_, __ 20 ,;l(r;,
12z. 81)-, 
NOTA Y PUBLIC 
My commission expires: 
",S1 )iY• .
i'1,,i rxo r:2 1 
BRITTANY CARTER 
Notary Pub He  Arizona 
Maricopa County 
Commlssion # 65:5274 
y Comm. Expires Jun.18, 2027 
(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 
/if known)l6\ 
Original Date of Issue 
c__ __ lif known\ 17\
37oD11l,lo\l 
'-"-----

\a1\?.!J;\\,, 
Reas911 for original issue of Warrant/Check (8):
G2I Payroll 
□For Services or Goods furnished. _______________ _
□Other: _______________________ _
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Schools\Schools-Warrants Checks notice of claim.doc 
Revised June 2015 
A.R.S. 11-632 & 15-999