Check Exchange/Cash Pick Request Form

 Empl        SS #                 Full Name                 TEoffice         Address On Return                 City          St       Zip

       Select One Akron Atlanta Baton Rouge Baltimore Charlotte Chicago Cincinnati Cleveland Columbus Dayton Detroit East St. Louis Flint Indianapolis Jackson Kansas City Lansing Lexington Louisville Little Rock Macon Memphis Miami Milwaukee Mobile Nashville New Orleans Norfolk Philadelphia Pittsburgh Richmond Shreveport St. Louis Toledo Washington      

Tax Refund  Prep Fee   Bank Fee   Discussed?     With Whom          Product                  Date            Time

       Select One Yes No    Choose One Check Exchange Cash Pick Insta Pick   

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