Lost or Stolen Check
Replacement Request
Employee Name
Lewis & Clark ID#
Please provide the following information to insure that the correct payroll
check is being voided and reissued:
Check One:
Student Payroll General Payroll (Faculty and Staff)
Check Number
Check/Payroll Date
I certify that the check indicated has been lost, stolen, or damaged and
request that Lewis and Clark issue a replacement check.
If you have questions or require further information in order to complete this form; please
contact the payroll office. Student PR x7820 Staff PR x7819
Deliver to the HR/Payroll Office, South Campus Chapel Annex Mail Stop Code: 72
Fax: 503-768-6233
This Section to be completed by the Payroll Office Only
Stop Payment Issue Date
Bank Confirmation Number
Replacement Check Date
Replacement Check Number
Print Form