Replacement check affidavit request form - Administration and Finance

Instructions

Complete this form online and select “submit” to have a copy of the completed form emailed to you. Print it, obtain all required signatures, and submit to the Payroll Office.

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 WD with this address?(Required)

Yes

No

Email(Required)

Check information

Check date(Required)

Check number(Required)

Check amount(Required)

Check date

Check number

Check amount

Check date

Check number

Check amount