Form AP004 "Vendor Payment Check Cancellation Request" - Delaware

What Is Form AP004?

This is a legal form that was released by the Delaware Office of the State Treasurer - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 15, 2017;
  • The latest edition provided by the Delaware Office of the State Treasurer;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AP004 by clicking the link below or browse more documents and templates provided by the Delaware Office of the State Treasurer.

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Download Form AP004 "Vendor Payment Check Cancellation Request" - Delaware

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STATE OF DELAWARE
  Office of the                                                               
 
Check Cancellation Request
State Treasurer                                                     
 
Submit
Reset
________________________________________________________________________________________________________________________ 
*This Form Must be completed in its entirety to request a payment cancellation.  Incomplete forms will not be accepted.
 
Date:
  ___________________      
Organization:  
________________________________________________________________      
Dept ID:
  _____________ 
Name of Requestor:
Telephone Number:
  _________________________________________________________________      
  _______________________ 
Requestor’s Email Address:
Fax Number:  ______
  ___________________________________________________________                    
________________ 
 
CHECK INFORMATION
 
Check Number:
  ________________________________________________________________________________________________________________ 
Date of Check:
  ________________________________________________________________________________________________________________ 
Payee:
  ________________________________________________________________________________________________________________ 
Voucher Number:
  ________________________________________________________________________________________________________________ 
Amount:
  ________________________________________________________________________________________________________________ 
 
REQUESTED ACTION
 
☐    Cancel Check and Do Not Reissue Check (must have possession of Check) 
☐    Stop Payment on Check and Reissue Check 
☐    Stop Payment on Check and Do Not Reissue Check 
Reason for 
 
Requested Action:   
_____________________________________________________________________________________________________ 
 
FOR REISSUE CHECK
 
☐    RE Mail Directly to Vendor                          ☐    RA Return Check to Agency
 
Return this form electronically or by mail.  All forms should include a copy of the voucher.  Cancellations should also include the original check.  Send forms and 
documentation to Lynsey Smith at Lynsey.Smith@state.de.us or to the Office of the State Treasurer, 820 Silver Lake Blvd. Suite 100, Dover (SLC D570D). 
For Questions, contact Lynsey Smith at Lynsey.Smith@state.de.us or 302‐672‐6718 
OFFICE USE ONLY
 
Date of Stop Payment:  
Reissued Check Number:  
Date:
________________________     
________________________     
  ________________________ 
 
Form # AP004 
Page 1 of 1 
Created: 08/15/2017 
STATE OF DELAWARE
  Office of the                                                               
 
Check Cancellation Request
State Treasurer                                                     
 
Submit
Reset
________________________________________________________________________________________________________________________ 
*This Form Must be completed in its entirety to request a payment cancellation.  Incomplete forms will not be accepted.
 
Date:
  ___________________      
Organization:  
________________________________________________________________      
Dept ID:
  _____________ 
Name of Requestor:
Telephone Number:
  _________________________________________________________________      
  _______________________ 
Requestor’s Email Address:
Fax Number:  ______
  ___________________________________________________________                    
________________ 
 
CHECK INFORMATION
 
Check Number:
  ________________________________________________________________________________________________________________ 
Date of Check:
  ________________________________________________________________________________________________________________ 
Payee:
  ________________________________________________________________________________________________________________ 
Voucher Number:
  ________________________________________________________________________________________________________________ 
Amount:
  ________________________________________________________________________________________________________________ 
 
REQUESTED ACTION
 
☐    Cancel Check and Do Not Reissue Check (must have possession of Check) 
☐    Stop Payment on Check and Reissue Check 
☐    Stop Payment on Check and Do Not Reissue Check 
Reason for 
 
Requested Action:   
_____________________________________________________________________________________________________ 
 
FOR REISSUE CHECK
 
☐    RE Mail Directly to Vendor                          ☐    RA Return Check to Agency
 
Return this form electronically or by mail.  All forms should include a copy of the voucher.  Cancellations should also include the original check.  Send forms and 
documentation to Lynsey Smith at Lynsey.Smith@state.de.us or to the Office of the State Treasurer, 820 Silver Lake Blvd. Suite 100, Dover (SLC D570D). 
For Questions, contact Lynsey Smith at Lynsey.Smith@state.de.us or 302‐672‐6718 
OFFICE USE ONLY
 
Date of Stop Payment:  
Reissued Check Number:  
Date:
________________________     
________________________     
  ________________________ 
 
Form # AP004 
Page 1 of 1 
Created: 08/15/2017