Application by Individual to Replace Lost or Destroyed Check
Vanderbilt University
Payroll Office
975 Baker Building 110 21st Ave South Nashville, TN 37203
Telephone: (615) 343-7000 Facsimile: (615) 343-0219
Application by Individual to Replace Lost/Destroyed or Stale Dated Check
Employee I.D# _______________________
____________________________________
(First Name)
(Initial)
____________________________________ (No. and Street)
____________________________________
(City)
(State)
Paycheck dated: _______________________
Amount: _____________________________
Date: _______________________ ______________________________ (Last Name) ______________________________ (Telephone) Zip Code_______________________
Check #________________________
Will Pick Up at Payroll Office_________
Mail___________________________
Request for replacement of Vanderbilt University Paycheck is being requested because:
___________________________________________________________________________________ (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.
X___________________________________
Date: ____________________________
PAYROLL USE ONLY Inquiry_______________ Reissue Information: Pay Group ____________
New Check# __________
Stop-pay _______________
Initial _______________
On/Off Cycle __________ Original PPE___________ Date: _________________
Process #_____________ Initial: _______________
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