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EMS Scholarship Stop Payment-Reissue Form

By completing this form, you are authorizing the Virginia EMS Scholarship Program to place a stop payment on a scholarship payment check that was issued to you. Stop payments will be processed after a mailed check has been outstanding for at least (45) business days. Forms may only be completed by the individual/agency to whom the refund check was issued. Processing may take up to 30 business days. Payment by direct deposit should be expected within 45 days (via electronic payment) and 60 days (via paper check). There may be a $30.00 processing fee for all reissued checks as outlined in program policies.

Recipient Name(*)

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Current Address(*)

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City(*)

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State(*)

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Zip(*)

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Email Address(*)

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Phone Number (123-456-7890)(*)

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Expected payment amount(*)

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Reason for Stop Payment-Reissue(*)

Address on check is correct, but never received

Address on check was incorrect (address changed)

Check was lost or damaged

Moved or changed address

Other

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Preferred Payment Method(*)

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Upload an updated W9 (pdf format required)(*)

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The IRS W9 form may be downloaded at https://www.irs.gov/pub/irs-pdf/fw9.pdf.

You must attest to the following before submitting this form:(*)

I verify that my mailing address listed on this form is correct.

I have attached an updated W9 Form.

I realize that this process can take up to 30 business days and that if I subsequently receive or recover the original check, it must be returned to the Virginia EMS Scholarship Program at 506 Piedmont Avenue, Bristol, VA, 24201.

If the original check is cashed or deposited, I will be responsible for repayment and/or subject to collection proceedings.

Stop Payment/Reissued checks may be assessed a $30 bank fee.

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By typing your initials, you verify that you have read and agree to all policies outlined in the Virginia EMS Scholarship Stop Payment/Reissue Policy and outlined on this form.(*)

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Type the code (numbers only) displayed(*)

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Virginia EMS Scholarship Program Financial Document Mailing Address 506 Piedmont Avenue Bristol, VA 24201 Information: