Replacement check affidavit request form - Administration and Finance

Instructions

Complete the online form and select “Send Form Information to My Email” to receive a copy of your responses. You must then print the email, hand-sign it, and return it to the Payroll Office to complete your request.

Employee Information

Name(Required)

First Last

Employee ID #(Required)

Date of request(Required)

Select one(Required)

Mail check to address below

I will pick up from payroll office

Contact phone #(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to update myURHR Workday with this address?(Required)

Yes

No

Email (University of Rochester email preferred)(Required)

Check information

If you need replacements for more than three checks, please complete and submit an additional online form.

Check date(Required)

Check number(Required)

Check amount(Required)

Check date

Check number

Check amount

Check date

Check number

Check amount

Acknowledgment

Required Confirmation(Required)

I understand that submitting this online form only emails me a copy of the information I entered. To complete my request, I must print the email, hand-sign the form, and return it to the Payroll Office.