ACH Stop Payment

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Member Information

Today's Date*

Account Number*

Account Holder Name*

Account Holder Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Holder Telephone*

Email*

Originating Company Name*

Amount of Transaction

Or Any Amount

Check If Any Amount

Check Serial Number*

(for check related debit entries only)

Please Specify*

Stop all future payments from this Originator indefinitely

Stop the next payment only: Future entries form this Originator are to be paid, unless I provide you with an additional stop payment order

Stop a series of payments

Identify the payment dates, or months of the specific payments form the Originator you wish stopped*

For pre-authorized entries, three business days advance notice prior to the expected transfer date of the debit entry is required to implement the stop payment request. If the stop payment order is received within three business days of the expected transfer date, we will attempt to satisfy the request of the account holder, but will not be held liable if sufficient time was not provided for a pre-authorized transfer that occurs within the three business day period. The account holder also understands that it is necessary to provide the correct information related to the transaction(s) sufficient to enable the identification of the account and transaction(s) in question.*

Yes

Account Holder Initials Here*

For all non-recurring, single transaction ACH payments, the stop payment request must be provided in a time-frame that allows reasonable opportunity for us to honor the request prior to finalizing the ACH entry. This form acknowledges the account holder’s request to stop payment on pre-authorized electronic funds transfers as indicated above. The account holder further represents that the debit transaction(s) described above was not originated with fraudulent intent by me or any person acting in concert with me, and that the signature below is my own proper signature.*

Yes

A fee of $20.00 will be assessed to the account holder as payment for implementing this order.

Signature of Account Holder*

Date*

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