Student Indemnity Agreement
Request for stop payment on a student account refund check
issued by ASU and request for refund credit.
1. I certify that on , 20 , ASU issued a check, number , in the amount of
$ ______ payable to .
2. Please check one | To the best of my knowledge, the check described above has been:
lost stolen damaged destroyed
I certify that I did not endorse the check and I did not deliver it to any other payee for endorsement. I understand ASU
will not accept a request for stop payment and replacement of a check for any check that has been endorsed “in
blank” — e.g., signature only with no restriction such as for deposit only or pay only to — because such a check is
considered a bearer instrument. I understand I must file a police report that contains my signature and I must present
a complete copy of that report to ASU if the check has been stolen. The original check must accompany this
indemnity agreement if the check has been torn, mangled or otherwise damaged.
3. I request ASU place a stop payment order on the check described above and issue me a replacement check. I agree
to indemnify and hold ASU, its successors or assignees, harmless from all claims, demands, losses,
damages, liabilities or judgments that may arise from or relate to the check and this request to stop payment.
Further, I will fully reimburse ASU for any expenses it may incur in ordering a stop payment of the check, or
in issuing a duplicate, while the original is still outstanding, including any attorney fees.
Check the following to allow processing to begin:
I authorize Student Accounts to issue a stop payment on the check listed above and,
I understand there is a $20 fee for reissuing student account refunds.
4. I agree to promptly pay ASU within five business days of verbal or written notice the full amount of the check,
together with all costs and expenses that ASU may incur relating to the check and the order to stop payment, if ASU
is unable to stop payment on the check and is obligated — as determined solely by ASU in the exercise of reasonable
discretion — to pay a holder who presents the check to ASU or its bank for payment. If I fail to promptly pay ASU
within five business days of notice, ASU may:
• Decline to permit me to register for future classes at ASU, place a hold on any release of my transcripts, and hold
on any diplomas that I might earn.
• File reports concerning the check and this agreement with law enforcement agencies, report to credit rating
services, credit collection agencies, and attorneys concerning this indemnity agreement, the requests made
herein and the facts upon which this request is made.
• Refer this matter to the appropriate ASU office(s) for disciplinary action on behalf of ASU.
5. If I find the check, I will mark “Void” on the front and then promptly return it to ASU for cancellation and
destruction.
6. I understand that ASU is not required to accept this request for stop payment and issuance of a replacement check.
ASU may, in its sole discretion, decline to stop payment on the check and it may decline to issue a replacement
check.
Student signature Date
Student printed name ASU ID number
Please verify a current address is updated on My ASU for a timely delivery.
ASU Financial Services | Revised 10/25/19
