Missing Check Form

• Please fill out all of the information below. Do not leave any spaces blank. Only GHPM employees are authorized to report a missing check. Forms submitted by anyone other than the employee will be rejected and considered invalid.
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• Required Information
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• First Name*
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• Last Name:*
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• Address:*
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• City*
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• State*

  TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
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• Zip Code*
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• Home Phone*(xxx-xxx-xxxx)
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• Cell Phone*(xxx-xxx-xxxx)
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• Email*(must be filled out to send form)
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• Assigned facililty:*
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• Pay Check Information
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• Pay date of missing check*
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• Approximate Check Amount: $*
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• Reason For Submitting Form
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• Form Submission Reason*

  Never received in mail(address has not changed with in the last 90 days)

  Never received in mail(address has changed with in the last 90 days)

  Lost Check

  Damaged Check

  Stolen Check

  Expired Check
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• Additional Information
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• Please....*

  Mail my check to the address on file.

  Mail this check to the address provided on this form. This is not my address on file.

  Hold my check to be picked up at the office.

  Deliver new check to my assigned facility.(Only available when pool is open full time)
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• Additional Information*Please provide any additional information in the space below.
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• Process Fee*By submitting this form, you may be subject to a Bank Processing Fee of $35.00 that will be deducted from your re-issued check.

  I agree to the $35.00 Bank Processing Fee.
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• Security Validationcopy the characters
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• Submit Form
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