Check Image Request Form
200 Piedmont Avenue, Suite 1604 West Tower, Atlanta, GA 30334 Phone (404) 463-1993, Fax (404) 463-5089
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Requesting Agency Name:
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Agency PeopleSoft Business Unit:
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Date Requested:
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Requested by:
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Requestor's Email Address:
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Phone Number:
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Select Check Type:
Payroll Check
A/P Check
Please complete the following information for each check copy.
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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
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Indicates Response Required