____________________________________________________________ ________________________
___________________ _____________________
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Behrakis One-Stop Student Center, Room SC-121A
100 Elliott Street, Haverhill, MA 01830
TEL: 978.556.3900 FAX: 978.556.3171
*Please Note, this form is not to be used for direct deposit refunds
Please complete all information below (incomplete forms will not be processed) and submit to STUDENT
ACCOUNTS OFFICE in person, mail or fax (address and fax above.)
Name Student I.D
Street Address
State Zip Code
Primary Phone Number
Please issue a duplicate check for the following reason:
I neve
r received the original check.
The original check was destroyed or lost.
Other Reason:
Check Date Check No.
Check Amount $
Semester (Optional)
______________ _______
I hereby authenticate that the above information is accurate. Additionally, if I do receive or find the original check I will not
cash it, and will immediately return the check to the Office of Student Accounts at the address above.
In the event that I cash, deposit, or receive via direct deposit both the original and replacement checks, I understand that I
will be responsible for any balance created by the duplicate refund. I understand that this balance will prevent future
registration, the release of transcripts, and graduation. If I fail to make payment when due, I understand that I may be
subject to collection activity, including litigation, for the entire amount owed plus late payment fees and collection costs.
Student Accounts Use ONLY:
Address_Ph Same as BANNER Address_Ph different and changed in BANNER DATE _______________ BY ________
Check Number _______________________________Check Date__________________ Check Amount_________________
Check Verified NOT Cashed Verification Attached Check Cashed Student Informed of Fraud Procedure
Form Sent to Finance: Staff________________________ Date ________________
Finance Department Use ONLY:
Stop Pay at Bank by: ________________________________ Date: ____________________________________________
Reissued and Mailed to Student; Check No: ____________________ Date: ______________________________________
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