Check Replacement Request Form

This form is used for the replacement of lost, destroyed or stale dated checks.
Updated 1/19/16

Name Name First Last
Email
Employee ID
Must be 7 digits. Currently Entered: 0 digits.
Date Date / MM / DD YYYY
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Paycheck dated
Check Number
Must be 7 digits. Currently Entered: 0 digits.
Check amount $ Dollars . Cents
Reason for request. (Please state all information known regarding the non-receipt, loss, theft, mutilation or destruction of check.)
I expressly agree to IMMEDIATELY notify the Vanderbilt University Payroll Office if I find or receive the Original Check at ANY TIME that it comes into my possession or control. Also, I will IMMEDIATELY surrender the original check to the Vanderbilt University Payroll Office. I understand that a replacement check will be made available no later than 3:00 p.m. on the FIFTH business day following the submission of this request. If upon further investigation or review, the replacement check was not due to me, I agree to IMMEDIATELY repay Vanderbilt University in full by either money order or by payroll deduction. I expressly agree to allow Vanderbilt University, at its sole discretion, the right to deduct from my pay any expense incurred if I fail to follow all these terms and conditions, including any banking fees, such as stop-payment or processing charges, collection and court costs, attorneys’ fees and interest. If these expenses are not paid by payroll deduction, I agree to pay them directly to Vanderbilt University.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY