WESTERN OREGON UNIVERSITY
Statement for securing a replacement payroll check
Print Name___________________________________________________________
Mailing Address_______________________________________________________
City/State/Zip Code____________________________________________________
Phone Number________________________________________________________
I state that I am the lawful payee of the Western Oregon University payroll check as
referred to below.
I am completing this statement in compliance with Oregon Revised Statute 293.475 to
obtain, from the Disbursing Officer of Western Oregon University, a duplicate check to
replace the lost, stolen or destroyed payroll check.
I understand that if the original check is found, it must be returned immediately to Western
Oregon University Payroll Office, 345 S. Monmouth Ave., Monmouth, OR 97361.
Original Check Number
_________________________________
Payroll Check Issue Date _________________________________
Net Amount of Check ____________________________________
Signature of Payee_________________________________________________________
____________________________________________
Social Security Number or V#
_________________________
Date of Claim
__________________I will pick up the replacement check in the Payroll Office with picture ID.
Mail Check to____________________________________________________________
_______________________________________________________________________
----------------------------------------------------------------------------------------------------------
PHARECN __________________________ Reconciled/Outstanding
Date Checked
(attach copy of PHARECN screen)
Approved_______________________________________________Date____________
Place a copy of the signed form with the replacement check.
Place original form in employee file.
Check Date____________________Manual Check Number_______________________