WOMAN'S
----------------- UN I VER SI TY '"
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CERTIFICATION
For Checks Lost, Destroyed, Stolen, or Not Received
Office of the Controller●Accounts Payable
SECTION A:
To be completed by the owner of the check
SECTION B:
To be completed by Bursar/Controller's Office
Owner Name Voucher No. Voucher Date
Address Check No. Check Amount Check Date
City, State, Zip
Preferred Disbursement Method Below:
Mail
Deliver to Bursar’s Office
Phone No./E-mail Address
CERTIFICATION
I certify I am the true owner, or the authorized representative for the owner, of the check described above and that the
information I furnish on this form is true and correct to the best of my knowledge and belief. I understand that I may be guilty
of a criminal offense by falsifying this certificate in order to obtain money to which I am not entitled.
I certify the check described above was: lost, destroyed, stolen, or not received.
I understand that a stop payment and cancellation will take place on this check upon receipt of this certification by Texas
Woman’s University. If I receive this check after completing this certification, I will immediately return the check to the
Texas Woman’s University at the address shown below.
SIGN
HERE
PRINT
NAME
DATE
RETURN CERTIFICATION FORM TO:
Texas Woman's University
Office of the Controller
P O BOX 425439
Denton, TX 76204-5439
OR
Email to Jmiller@twu.edu or TWUPayables@twu.edu
FOR QUESTIONS CALL 940-898-3532
