STAMPED AND REDACTED - 3700969129 - ZANE BATES.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/Check (definitions are on page 21 
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. 
ɪ
ll
"'=> Ml L-Lɫ12f><l---'IZ (1), being first sworn, upon oath deposes and says;
Name Claimant 
o, L..\... cn.J 
On or about 
'=-\I Ct.\ 2..0 
(ctate)(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/check be issued to him/her in the sum of$ 
I ,OU 2. , 00 
Signed:,.?ɬɭ
(4) 
(5) Subscribed and sworn to before me this 
I 
day of Jvv,,(_
?';:i,:-#, c-l-/c;k;,y c:11/rf?::c/:-:::, c:,;/:,_'227c: -'-
NOTARY PUBLIC 
t/ 
-
-
MAR!A l)E t,.0$ ANGELES FLETCHER P 
My com1
ission expire&:
M- • ' 
Notary Public • AriZOOl 
-;,.' :r. 
f 
M4rlcep11 County 
N 
Comm!nton II 665265 
O."J o L (__ 21);;!. 
My Comm. E):plrff Mar 1, 2028 
' 
.(3) 
20 QL.... 
(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) /6) 
'3 'l O C> C\ \Oc'\ \ '.2. ?) 
Original Date of Issue 
ts I IC\\ =-Lf' 
(if known) (7) 
Req_5i0n for original issue of Warrant/Check (8):
[)-.Payroll 
D For Services or Goods furnished _______________ _ 
D 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