Check Replacement Request

"*" indicates required fields

Today's Date*

Check Date*

Check Number

Check Amount

Employee Number*

My Esparza Supervisor Is*

Name*

First Last

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

I attest that my paycheck has been:*

Lost

Stolen

Destroyed

Never Received

Expired

I was present all day at my assigned work site on Payday:*

True

False

I am a current employee of Esparza Enterprises, Inc.:*

True

False

The facts related to the paycheck being lost/stolen/destroyed/never received are as follows:*

Attestation*

I have not negotiated, deposited, or cashed the Paycheck and I do not know of anyone else who has negotiated, deposited or cashed the Paycheck.

I agree that if a new Check is issued to me to replace the Paycheck, and I later find or am provided with the Paycheck, I will not negotiate, deposit, or cash the Paycheck and will instead return the Paycheck to ESPARZA ENTERPRISES, INC.

Based on the above, I hereby request that a new check be issued to me to replace the Paycheck.

If my request is approved, I would like my check delivered in the following manner:*

Mailed to my current address

Pick up at Office

If Pickup, Please enter Office Location*

Consent*

Legal Oath

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Employee Signature*

Name

This field is for validation purposes and should be left unchanged.

Click for an Info Request Form

3851 Fruitvale Avenue Bakersfield, CA 93308

Now HIRING! Please call (661) 631-0347 | Tel: 661-831-0002 | Fax: 661-831-0040

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