- This is the information of the person writing the check. It must include full name and complete address.
- This is the date that the check is written. The date can be spelled out such as "July 8, 2019" or by using numbers such as "7/8/2019.” Please no post-dated checks.
- This is to whom you are writing the check. Checks should be made payable to State Health Department.
- This is the amount of money the check is for. In this box, the amount is written in numbers. For example, 12.00.
- This is also the amount of money the check is for, but this time the amount is written in words. For example, twelve dollars and 00/100. The 00/100 represents zero cents.
- This is a memo. The memo line is mostly used as a reminder of what the check was for.
- This is where the checked is signed. The signature should match the name(s) in Part 1.
*Starter Checks are not accepted.
**There is a $50.00 service charge for returned checks.