APPLICATION TO PLACE STOP PAYMENT ON A CHECK ISSUED BY UM-FLINT
Name: UM ID or Social Security Number:
Phone Number: Home: Work:
Whose address is:
(Number and street) (City) (State) (Zip)
Represents to The University of Michigan-Flint that he/she is the owner of the check (checks) described below,
and that he/she has requested payment of said check (checks) be stopped.
Name of Paye
moun
Check
Date
List below the reason(s) for making application for a substitute check(s). (ex: check lost, check destroyed, check
never received, etc.)
Was the check endorsed? yes______ no_______
If yes, state exact manner of all endorsements appearing on the check:
I hereby agree that if I should receive the check after asking that Stop Payment be placed, I will not cash it, but
will surrender it immediately to The University of Michigan-Flint.
Date:
Signature:
A stop payment will be placed on the above check immediately. Please notify us if the check should be found.
Cashier's/Student Accounts - stop payment form.xls - http://www.umflint.edu/studentaccounts/forms/stop_payment.pdf
(Print first name, middle initial, last name)
