EmailMe Form - Stop Payment/Reissue Paycheck Form

Store Number *

Email (for submission confirmation) *

Employee Name *

First Last

Last 4 of Social *

Phone # you may be reached at *

### - ### - ####

Paycheck Date *

MM / DD / YYYY

Reason for replacement check *

Reason if Other

Check Receive Options *

Send Check to the Store

Send Funds to Branch Card

Send Check to Provided Address

Address to send replacement check if store location is not wanted

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

Todays Date *

MM / DD / YYYY

Notes/Comments:

I certify under the penalty of law that I am the employee requesting the stop payment or the employer on request of the employee *

Yes

No

Signature *

Clear

Signing here I aknowledge the above listed check will have a stop payment placed on it. I will receive a replacement check at the store within 2 weeks unless an address is specified above. I understand there will be a $25 fee unless a damage check is returned to the store. If the original check has been or ever is cashed, I agree to assist the company in seeking to recover these funds. Further, if through some misunderstanding, I am the recipient of funds from the original and replacement checks, either directly or through deposit of funds, I will repay the company by check or cash for the full amount of the original check, due immediately.