STOP PAYMENT and RE-ISSUE CHECK REQUEST FORM

Affidavit & Indemnity

I certify that my payroll check was: [ ] Not Received [ ] Lost/Stolen

I certify that my payroll check was: [ ] Endorsed [ ] Not Endorsed

This completed form will authorize the Payroll Department to take necessary action to stop
payment on the below mentioned check. You may turn in the completed form to Human
Resources, CM274.

Please note that 24 hours must elapse between stop payment and check re-issue.

Name____________________________________________________________

Address__________________________________________________________

_________________________________________________________________

Employee ID___________________or Social Security #__________________

Check Date____________________Check #____________________________

Pay Period_____________________Check Amount______________________

Please Check One:

[ ] Mail Check [ ] Hold in HR [ ] Campus Mailbox #__________

The undersigned now requests that NCC issue a replacement check on the express condition that the undersigned
agrees and undertakes to indemnify, defend, and hold NCC harmless from and against loss, damage, claim or
demand NCC may incur if the original check is presented, produced or paid.

On demand the undersigned will pay or otherwise reimburse NCC the full amount of any loss or damage of
whatever kind NCC sustains by reason of the negotiation, payment, production, or presentment of the original check
which the undersigned has alleged to be lost, mislaid, destroyed, or stolen, together with all costs, charges,
reasonable attorney fees and expenses of NCC in its reliance on this Affidavit and Indemnity.

Signature_________________________________Phone___________________Date_______