Systems and Procedures
A Division of The Corporate Controller's Office


Form Instructions

  1. Check Number - From the issued check to be cancelled, enter the check number. Only one check per form.
  2. Check Date - Enter the date of issue on check to be cancelled.
  3. Amount - Enter the amount of the issued check to be cancelled.
  4. Payee - Enter to whom the check was made payable.
  5. Address - Enter the address of the payee (if available).
  6. Reason - Enter a detailed reason why the check is to be cancelled.
  7. Requestor - Enter the person’s name requesting the check to be cancelled
  8. Requestor's Department - Enter the requestor's department name.
  9. Requestor's Phone - Enter the requestor's telephone number.
  10. Budget Code Table - This table has seven columns with one header row and three data rows.The table is for the distributon of charges from the request for payment that was originally submitted.
  11. The requestor’s signature and date.
Image of Check Cancellation Form