STAMPED & REDACTED - FOR AGENDA ATTACHMENT - DELTA T GROUP.PDF

Schools Affidavit/Claim Form 
Application for a Duplicate Warrant/ Check (definitions are on page 2)
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. 
_D'T'IE=LTžAn::T=GŸR_O_U_P ______ {1), being first sworn, upon oath deposes and says: 
Name1Cla1mant 
On or about 12/1/2023 
{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, 9.[ 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 i 
r in the sum of $_3_.4_3_8_.0_0 ______ .{3) 
Commonwealth of Pennsylvania • Notary Seal 
SHANNON SERGI· Notary Public 
Delaware County 
My Commission Expires f'eb 24, 20)◄ 
Commission Number 129613$ \Seal} 
Note: Please attach a copy of the warrant/check if available and/or an)' other 
evidence that a warrant/check was originally issued 
Warrant/Check Number 
3700717535
(If known) (6) 
Original Date of Issue 
12/1/2023
(If known) (7) 
Reason for original issue of Warrant/Check (8):
□Payroll
i!! For Services or Goods furnished Substitues
·---------------
□Other: Substitues
S:\PROCESSES\Warrants • Duplicate or Stale\02 Fonns\Schoots\Schoo
 
 
  
 
Revised June 2015