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Request for Stop Payment and Replacement Check

If a check has been lost or not received, you may submit this request to be issued a replacement check from the Accounting Department.

After submitting this form, you will receive an email with a copy of the completed form for your records.

Receive This Form by Mail or Pick-Up

If you do not want to complete this form online, you can call our main office to have it mailed to you. You can also pick it up in the office.

Berkeley Housing Authority
1947 Center Street Fifth Floor, Berkeley, CA 94704
Telephone: (510) 981-5470   Fax: (510) 981-5480

Request for Stop Payment and Replacement Check

"*" indicates required fields

Claimant/Authorized Agent's Contact Information

Name*
Company Name (if applicable)
Email*
Address*

Check Information

MM slash DD slash YYYY
Payment For:*

Declaration

I declare that I have LOST or NOT RECEIVED the check described above:*
Said check HAS or HAS NOT been endorsed by me:*
Verify*
MM slash DD slash YYYY

 

Berkeley Housing Authority logo

Berkeley Housing Authority
1947 Center Street Fifth Floor, Berkeley, CA 94704
Telephone: (510) 981-5470   Fax: (510) 981-5480