Stop Payment/Void Check Request Form
Current Mailing Address:
Street City State Zip
*Address must be current in Banner before check is reissued
Remit to: Disbursing
Mail to Address Above
Payroll Student Accounts
Type of Request: Stop Pay & Reissue
Void/Do Not Reissue
(Attach check)
Stop Pay-Title IV Return
Void & Reissue
(Attach check)
Reset Form
Print
Reason for Stop Payment/Void:
Check Not Received by Vendor Destroyed
Lost Stale Dated Other
Explanation if “Other”:
Check Number: ________________________________________
(FAIVNDH)
Date of Check: _____________________________________
Amount of Check: _________________________________________
T Number: _______________________________________
Vendor Name: __________________________________________
If a reissuance is needed and the university does not have possession of the check, the
payee must sign the following statement:
Please process a stop payment and reissue the above mentioned payment. If the original check is found
or delivered to me at a later date, I will return it promptly to the University. Arkansas Tech University
reserves the right to charge the payee the cost of the checks and any other costs incurred plus interest in
the event that both checks are cashed by the payee.
Signature of Payee
:
For Controller’s Office Use Only:
Confirmation check is outstanding (initial & date):
Stop Payment entered at bank
(initial & date)
:
Check Cancelled/Voided in Banner (initial & date):
Check Cancelled/Voided in Evisions
(initial & date)
:
