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 Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal 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. reCAPTCHA If you are human, leave this field blank.