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Request to Bank for Front and Back Cancelled Check - PDF

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					                                                Division of Financial and Business Services                                     Clear Form
                                                           Bank Reconciliations
                                                  ChECK VErifiCation form                                                            Print



This form is to be used to verify the status of a university check. Please provide the check number, amount, date of the
check, and indicate the appropriate account type.

Please note that outstanding or stale dated checks (outstanding for more than 180 days on most checks) may be re-
issued by completing the Check Re-Issuance Form.

Type of Request:      q Copy of the Cancelled Check (front/back)
                      q Date of Bank Paid ___________________________
                      q Date Check Outstanding as of __________________


ACCOUNT INFORMATION: (select one)
☐ Payroll Account; Administrator: Nancy Ho, nancyho@usc.edu, 213-821-2809 (90 days)
☐ Disbursement Control Account; Administrator: David Ramirez, david.ramirez@usc.edu, 213-821-2811 (180 days)
☐ Hospital Disbursement Control; Administrator: David Ramirez, david.ramirez@usc.edu, 213-821-2811 (180 days)
☐ Delta Health Systems Account; Administrator: Ba Shai Lagarde, blagarde@usc.edu, 213-821-2815 (180 days)
☐ USC Senior Care Account; Administrator: Ba Shai Lagarde, blagarde@usc.edu, 213-821-2815 (180 days)
☐ Bursar Account; Administrator: Mary Jo Magbuhos, magbuhos@usc.edu, 213-740-7388 (180 days)


      Check Number                                      Payee Name                                         Amount                Check Date




Requested By: ______________________________________________                     Phone: _________________________________________

Address/MC: _______________________________________________                      FAX: __________________________________________

Requestor’s Email Address: _____________________________________________________________________________________________

Additional Information: _______________________________________________________________________________________
_____________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________




            University of Southern California, Financial & Business Services, Bank Reconciliations, Los Angeles, California 90089-8012
                                    Tel: (213) 821-2809 Fax: (213) 821-2818 http://fbs.usc.edu/depts/bankrecs
                                                                                                                         Form br-cvf (Rev. 06-2011)
                                                 Clear Form                       Print

				
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