STAMPED AND REDACTED - 3700896930 - CPR SOLUTIONS.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check 
MAR11 
COUNT 
(definitions ore on page 2) 
STATE OF ARIZONA 
COUNTY OF MARICOPA 
Note: Numbers on this form correspond to numbers on the 
Instruction sheet which Is page 2 of this form. 
ВCPR Solutions ____ ("I), being first sworn, upon oath deposes and says: 
Name/Claimant 
On or about __August 14, 2025 ___ (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 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/c eek be issued to him/her in the sum of $_1so.oo _____ , (3) 
Signed:_ j. 
da.u , 
(4) 
Print name: (require I Гyny,_e_Jo_f_d_an 
____________ _ 
(5) Subscribed and sworn to before me this . , I 11:1- day of DE:C!3Y&20J:s:
\ 'f/ 
1-ltД}vl: i _. Cl ,Dev, IY\JJ)
Y PUBLIC 
'
M
L /°+m/ ission
.
expires: 
Q- l 1 )._<;/)In 
•
STEPHANIE R. BARNES
Nolary Publ0 • Slala of l\rll008 
MARICOPA COUNTY 
. 
eommlss!On o 640664 
Expires t)eeefllber 14, 2026 
(seal) 
Note: Please attach a copy of tile warrant/c/Jeck if available and/or any other evidence 
that a warrant/check was originally issued. 
(if known) (6} 
3700896930 
Warrant/Check Number 
J
-o-,-·ig--i-na-l
c-"
(Е
"-
.
/
"'
kЖ
"'
З
"""
wИ
"'
I
-'
!
1c,,s
l
s_u_e __ -+---os_/_l_4/_2_0_25-. ------_ -_-_-_-_-_-:::::::Й11К--.-.-. . .
Reason for original issue of Warrant/Check (8):
□ Payroll 
Л For Services or Goods furnished. 
□Other:
S:\FlnanreDesk\Schools·Warrants Checks notice of dalm.docx 
Revised May 2025 
A.R.S. 11-632 & 15-999 
..