Check Image Request Form
200 Piedmont Avenue, Suite 1604 West Tower, Atlanta, GA 30334 Phone (404) 463-1993, Fax (404) 463-5089
Requesting Agency Name:
Agency PeopleSoft Business Unit:
Date Requested:
Requested by:
Requestor's Email Address:
Phone Number:
Select Check Type:
Payroll Check
A/P Check
Please complete the following information for each check copy.
Check Number:
Date Check Issued:
Amount:
Payee Name:
Vendor Number/Employee ID#:
Check Number:
Date Check Issued:
Amount:
Payee Name:
Vendor Number/Employee ID#:
Check Number:
Date Check Issued:
Amount:
Payee Name:
Vendor Number/Employee ID#:
Check Number:
Date Check Issued:
Amount:
Payee Name:
Vendor Number/Employee ID#:
State Accounting Office Use Only
Processed By SAO:
Date:
Check Number:
SAO Form: 100-D
Indicates Response Required