Fillable Stop Payment/ Cancel Stale Dated Check Request Form printable pdf download

UCSD BFS PAYROLL

STOP PAYMENT/ CANCEL STALE DATED CHECK

REQUEST

___________________________________________________________________________ says as follows:

(NAME OF DECLARENT & METHOD OF CONTACT)

I have been informed that a check drawn by the Regents of the University of California against its account maintained

with Wells Fargo Bank, check #

__________________, dated _________________ in the amount of

$________________, was issued to ________________________________________as payee.

I am the legal owner or entitled to possession of said check and said check has been (destroyed), (lost), and the facts of

such (destruction), (loss), (stale) in so far as known to me are as follows:

______________________________________________________________________________________

The payee of said check has not negotiated, deposited or cashed.

4a. STOP PAYMENT: I agree that, if a new check is issued to me in lieu of check # _________________, which has been

lost, and if said check hereafter is placed in my possession, I will not negotiate, deposit or cash said check, but forthwith

will deliver the same to the Regents of the University of California for cancellation.

STALE DATED:

4b.

I understand, that if a new check is issued to me it replaces check #________________, that is no

longer negotiable as a result of an invalid date and the inability of financial institution to negotiate or cash this check.

Processing of a stale dated check may take 4-6 weeks from the date this signed certification is received.

I further agree that, for and in consideration of the re-issuance to me of a check in lieu of the check originally issued and

subsequently lost or destroyed, I will indemnify and hold harmless the Regents of the University of California against

loss, damage, expense of any other liability which may be suffered by said The Regents, either directly or indirectly, by

reason of the issuance of said duplicate check or by the original instrument still remaining outstanding.

Based upon the foregoing declaration and subject to the foregoing conditions, I hereby request that the Regents issue a

new check to me in lieu of check # __________________.

I certify, (or declare) under penalty of perjury that the foregoing is true and correct.

Signature of Payee: _____________________________________

Dated:_______________________

Mailing address of declarent: __________________________________________________________________

__________________________________________________________________

Check disposition:

For pickup ________, Send to mail code __________, Mail to home address __________

If not picked up in 5 business days from stop payment date, check will be mailed to the department.

Incomplete forms will be delayed.

PAYROLL USE ONLY

Fund#__________, Account#__________ Employee # _____________, PAYAUTH Doc # _____________

BANK REFERENCE

Stop payment processed on ___________________, by ____________________________________________

Stop pay accepted? Yes ___, No ___, if yes provide PC ref./Bank contact name _________________________

FORM MUST BE RECEIVED BY 3:30 P.M. PLEASE FAX BACK TO 858-534-7423.

Stop Payment/ Cancel Stale Dated Check Request Form