AFFIDAVIT
FOR APS
ALBUQUERQUE PUBLIC SCHOOLS
COUNTY OF BERNALILLO
)
)
)
SS
I, ____________________________________, Being first duly sworn, state that I paid
for charges/fees in the amount of $___________ , from ________________________,
but original receipt(s) were lost or never received.
ITEMIZED/DESCRIPTION(must complete this section):
DESCRIPTION
AMOUNT
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
_______________________$_________
TOTAL OF MISSING RECEIPT: $__________
Signed:_____________________________
Title:_______________________________
Subscribed and Sworn before me
This ________Day of___________, 20_______.
Notary Public
My Commission Expires:
REVISED FEBRUARY 24, 2010