EXHIBIT L
New 8/98

CHECK REISSUE REQUEST FORM

Return or mail to:
 
Agency Name
Address
Address
Address
Name/Address __________________ Social Security or FEIN#____
__________________ Telephone # ___________
__________________

**************************************************************

I certify that the check issued for _____________________ in the amount of__________ has been lost or has not been received by me. I request a new check be issued to me at the above address. (I understand that, should I receive/locate the original check, I will return it to the (AGENCY)).

**************************************************************

 

______________________________
Signature

__________________
Date

Back to Comptroller's Home Page
Back to Table of Contents