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SignatureDate Phone Number E-Mail Street Address City State Zip Please email mail or submit the completed form to Florida Atlantic University Annette Blackwell ablackwe fau. Office of the Controller Student Financial Services SU80/Room 130 777 Glades Road Boca Raton FL 33431 tel 561. 297. 6101 www. fau. edu DUPLICATE CHECK REQUEST FORM Please enter or print all information below I Identification Number Z request that a duplicate check be issued for the following reason s I never received the original check. The original check was destroyed or lost. OTHER REASON ORIGINAL CHECK AMOUNT I hereby authenticate that the above information is accurate. Additionally if I do receive or find the original check I will not cash the check but immediately return the check to the Controller s Office Student Financial Services Department SU80/Room 130. In the event that I do cash or deposit both the original and replacement checks I understand that the Controller s Office will post the amount onto my student financial account refer my account to a collection agency which will send my student account to the three 3 major credit bureaus. Office of the Controller Student Financial Services SU80/Room 130 777 Glades Road Boca Raton FL 33431 tel 561. 297. 6101 www. fau. edu DUPLICATE CHECK REQUEST FORM Please enter or print all information below I Identification Number Z request that a duplicate check be issued for the following reason s I never received the original check. 297. 6101 www. fau. edu DUPLICATE CHECK REQUEST FORM Please enter or print all information below I Identification Number Z request that a duplicate check be issued for the following reason s I never received the original check. The original check was destroyed or lost. OTHER REASON ORIGINAL CHECK AMOUNT I hereby authenticate that the above information is accurate. The original check was destroyed or lost. OTHER REASON ORIGINAL CHECK AMOUNT I hereby authenticate that the above information is accurate. Additionally if I do receive or find the original check I will not cash the check but immediately return the check to the Controller s Office Student Financial Services Department SU80/Room 130. Additionally if I do receive or find the original check I will not cash the check but immediately return the check to the Controller s Office Student Financial Services Department SU80/Room 130. In the event that I do cash or deposit both the original and replacement checks I understand that the Controller s Office will post the amount onto my student financial account refer my account to a collection agency which will send my student account to the three 3 major credit bureaus. Office of the Controller Student Financial Services SU80/Room 130 777 Glades Road Boca Raton FL 33431 tel 561. 297. 6101 www. fau. edu DUPLICATE CHECK REQUEST FORM Please enter or print all information below I Identification Number Z request that a duplicate check be issued for the following reason s I never received the original check. The original check was destroyed or lost. OTHER REASON ORIGINAL CHECK AMOUNT I hereby authenticate that the above information is accurate.

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