Missing Check Form

Please fill this form out if your check was lost, damaged, or stolen. If your check is incorrect, please fill out the Check Discrepancy Form.

Missing Check Form

First Name

Last Name

Cell Phone

Home Phone

Email

Address

Employee Pin (Last 4 of Social Security Number)

Assigned Facility

Missing Check Pay Date

Net Amount

Submission Reason *

Never received by mail (no change of address)

Never received by mail (change of address)

Never received at my assigned facility

Lost

Damaged

Stolen

Expired

Additional Information *

Please mail my check to the address on file.

Please mail this check to the address provided on this form. (No address on file)

Please hold my check to pick up at the APMI office.

Please deliver new check to my assigned facility.

Additional Information *

Process Fee - I acknowledge that I may be subject to a Bank Processing Fee of $25.00 that will be deducted from my next check for the reissued check. *

I agree to the $25.00 Bank Processing Fee.

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